Provider Demographics
NPI:1306090279
Name:PETRIC, VICKIE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:PETRIC
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 W 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2176
Mailing Address - Country:US
Mailing Address - Phone:719-463-1382
Mailing Address - Fax:
Practice Address - Street 1:11800 W 49TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2176
Practice Address - Country:US
Practice Address - Phone:719-463-1382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$Medicaid