Provider Demographics
NPI:1427468388
Name:CARL PETITTO OT PLLC
Entity type:Organization
Organization Name:CARL PETITTO OT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETITTO
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:315-782-0440
Mailing Address - Street 1:21101 STATE ROUTE 12F
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1078
Mailing Address - Country:US
Mailing Address - Phone:315-782-0440
Mailing Address - Fax:315-782-5349
Practice Address - Street 1:21101 STATE ROUTE 12F
Practice Address - Street 2:SUITE 5
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1078
Practice Address - Country:US
Practice Address - Phone:315-782-0440
Practice Address - Fax:315-782-5349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ1001525789Medicare PIN
NY7152150001Medicare NSC