Provider Demographics
NPI:1992084826
Name:DOBBS, PETULA ETHEL (DI)
Entity type:Individual
Prefix:MS
First Name:PETULA
Middle Name:ETHEL
Last Name:DOBBS
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:STEARNS
Mailing Address - State:KY
Mailing Address - Zip Code:42647-1005
Mailing Address - Country:US
Mailing Address - Phone:606-376-4479
Mailing Address - Fax:
Practice Address - Street 1:275 E MAIN STREET HS2W C
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40621-0001
Practice Address - Country:US
Practice Address - Phone:502-564-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201128735222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist