Provider Demographics
NPI:1720107980
Name:PETITGOUT, DEANN (LAT, ATC)
Entity type:Individual
Prefix:MRS
First Name:DEANN
Middle Name:
Last Name:PETITGOUT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SHERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-1151
Mailing Address - Country:US
Mailing Address - Phone:815-747-9922
Mailing Address - Fax:
Practice Address - Street 1:1550 CLARKE DR
Practice Address - Street 2:MS 1757
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3117
Practice Address - Country:US
Practice Address - Phone:563-588-6415
Practice Address - Fax:563-588-6666
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer