Healthcare Provider Details

I. General information

NPI: 1255288304
Provider Name (Legal Business Name): KORINNE NICOLE PETRIS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 VESPER AVE
SHERMAN OAKS CA
91411-4221
US

IV. Provider business mailing address

82 DOW JONES ST UNIT 2
HENDERSON NV
89074-8982
US

V. Phone/Fax

Practice location:
  • Phone: 747-277-3990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: