Provider Demographics
NPI:1477872539
Name:PETRIE, MARY A (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:PETRIE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 RIVERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2030
Mailing Address - Country:US
Mailing Address - Phone:434-200-5032
Mailing Address - Fax:434-200-1294
Practice Address - Street 1:693 LEESVILLE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2828
Practice Address - Country:US
Practice Address - Phone:434-200-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005118225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396706065Medicaid
496612OtherMEDICARE
VA1396706065Medicaid