Provider Demographics
NPI:1154049831
Name:PETRINO, CORA
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:PETRINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORA
Other - Middle Name:
Other - Last Name:MARICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 OLD CART RD
Mailing Address - Street 2:
Mailing Address - City:HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06438-1271
Mailing Address - Country:US
Mailing Address - Phone:860-331-3129
Mailing Address - Fax:
Practice Address - Street 1:5871 HARBOUR VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3669
Practice Address - Country:US
Practice Address - Phone:757-512-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5656225X00000X
VA0119-009650225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist