Provider Demographics
NPI:1730423864
Name:PETIT, AMY THANH (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:THANH
Last Name:PETIT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:THANH
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:196 MACON ST
Mailing Address - Street 2:1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2405
Mailing Address - Country:US
Mailing Address - Phone:714-653-0430
Mailing Address - Fax:
Practice Address - Street 1:196 MACON ST
Practice Address - Street 2:1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2405
Practice Address - Country:US
Practice Address - Phone:714-653-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21197235Z00000X
NY025372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist