Provider Demographics
NPI:1770049249
Name:PETIT, LEEZ-BETINA
Entity type:Individual
Prefix:
First Name:LEEZ-BETINA
Middle Name:
Last Name:PETIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GALLAWAY LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-3226
Mailing Address - Country:US
Mailing Address - Phone:908-494-5150
Mailing Address - Fax:
Practice Address - Street 1:14 GALLAWAY LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-3226
Practice Address - Country:US
Practice Address - Phone:908-494-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00149800171100000X
171100000X
NJ38MC00760000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist