Provider Demographics
NPI:1770513657
Name:PETTEY, GALEN WAYNE (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:GALEN
Middle Name:WAYNE
Last Name:PETTEY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3209
Mailing Address - Country:US
Mailing Address - Phone:707-443-8354
Mailing Address - Fax:707-443-8628
Practice Address - Street 1:2600 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2536
Practice Address - Country:US
Practice Address - Phone:707-725-6995
Practice Address - Fax:707-725-9152
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 22807174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT228071Medicare ID - Type Unspecified