Provider Demographics
NPI:1336144864
Name:DEPETRO, LINDA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:M
Last Name:DEPETRO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 ROUTE 299
Mailing Address - Street 2:STE 1
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2552
Mailing Address - Country:US
Mailing Address - Phone:845-691-9169
Mailing Address - Fax:845-691-3864
Practice Address - Street 1:280 ROUTE 299
Practice Address - Street 2:STE 1
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2552
Practice Address - Country:US
Practice Address - Phone:845-691-9169
Practice Address - Fax:845-691-3864
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003367-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY437112OtherMVP
NY111553OtherWELLCARE
NY18277OtherHUDSON HEALTH PLAN
NY000000011553OtherGHI HMO
NYQ77061OtherBLUE CROSS/BLUE SHIELD
NY10034266OtherCDPHP
NY10034266OtherCDPHP