Provider Demographics
NPI:1336810050
Name:PETUSKY, KIMBERLY (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PETUSKY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2447 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-3118
Mailing Address - Country:US
Mailing Address - Phone:570-316-8232
Mailing Address - Fax:
Practice Address - Street 1:58 NEITZ RD
Practice Address - Street 2:
Practice Address - City:NORTHUMBERLAND
Practice Address - State:PA
Practice Address - Zip Code:17857-9608
Practice Address - Country:US
Practice Address - Phone:570-473-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000695208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation