1629132337 NPI number — MS. BETHANY G. PETRELLA P.T. , M.S.P.T.

Table of content: MS. BETHANY G. PETRELLA P.T. , M.S.P.T. (NPI 1629132337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629132337 NPI number — MS. BETHANY G. PETRELLA P.T. , M.S.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRELLA
Provider First Name:
BETHANY
Provider Middle Name:
G.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T. , M.S.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629132337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
76 TINKERVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06279-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-429-0403
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 POMFRET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-928-9444
Provider Business Practice Location Address Fax Number:
860-928-4811
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  004177 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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