Healthcare Provider Details

I. General information

NPI: 1326632779
Provider Name (Legal Business Name): MARY AMANDA PETACCHI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 DELAWARE AVE STE 2
DELMAR NY
12054-1135
US

IV. Provider business mailing address

257 DELAWARE AVE STE 2
DELMAR NY
12054-1135
US

V. Phone/Fax

Practice location:
  • Phone: 845-633-3866
  • Fax:
Mailing address:
  • Phone: 845-633-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number031147
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number031147
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number031147
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: