Provider Demographics
NPI:1831387554
Name:PETTY, CYNTHIA M (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:M
Last Name:PETTY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-4544
Mailing Address - Country:US
Mailing Address - Phone:508-678-6245
Mailing Address - Fax:
Practice Address - Street 1:333 GREEN END AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5620
Practice Address - Country:US
Practice Address - Phone:508-728-9879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00109224Z00000X
MA1967224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant