Healthcare Provider Details

I. General information

NPI: 1245217066
Provider Name (Legal Business Name): CARL ANTHONY PETITTO OT/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22567 SUMMIT DR BLDG 2
WATERTOWN NY
13601-7210
US

IV. Provider business mailing address

22567 SUMMIT DR BLDG 2
WATERTOWN NY
13601-7210
US

V. Phone/Fax

Practice location:
  • Phone: 315-779-6784
  • Fax: 315-779-6799
Mailing address:
  • Phone: 315-779-6784
  • Fax: 315-779-6799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0107001
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: