Healthcare Provider Details

I. General information

NPI: 1629560990
Provider Name (Legal Business Name): NICOLE MARIE PETRUSO OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2018
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8030 LA MESA BLVD # 416
LA MESA CA
91942-0335
US

IV. Provider business mailing address

8826 JACKIE DR
SAN DIEGO CA
92119-1418
US

V. Phone/Fax

Practice location:
  • Phone: 619-567-9448
  • Fax:
Mailing address:
  • Phone: 619-992-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number26623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: