Provider Demographics
NPI:1952429243
Name:PETTIT, CECILE PERIGARD (RPT)
Entity type:Individual
Prefix:MS
First Name:CECILE
Middle Name:PERIGARD
Last Name:PETTIT
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROCKLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-2345
Mailing Address - Country:US
Mailing Address - Phone:203-757-2167
Mailing Address - Fax:
Practice Address - Street 1:45 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3214
Practice Address - Country:US
Practice Address - Phone:860-378-1234
Practice Address - Fax:860-378-1160
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080001501CT02OtherBLUE CROSS
CT11244033OtherCAQH