Provider Demographics
NPI:1215387568
Name:PETTINATO, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PETTINATO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W 239TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1205
Mailing Address - Country:US
Mailing Address - Phone:917-743-1572
Mailing Address - Fax:
Practice Address - Street 1:521 W 239TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1205
Practice Address - Country:US
Practice Address - Phone:917-743-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039006-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker