Provider Demographics
NPI:1982993937
Name:PETTI, VENITA JILL (OT/L)
Entity Type:Individual
Prefix:
First Name:VENITA
Middle Name:JILL
Last Name:PETTI
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 W QUINN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2425
Mailing Address - Country:US
Mailing Address - Phone:208-233-4800
Mailing Address - Fax:208-233-4886
Practice Address - Street 1:1033 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-233-4800
Practice Address - Fax:208-233-4886
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-455225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1654526Medicare Oscar/Certification