Healthcare Provider Details

I. General information

NPI: 1174691000
Provider Name (Legal Business Name): CHRISTINE DENISE PETTERSON OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE DENISE KENNEDY OTR

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 SHELBURNE RD SUITE 8
SHELBURNE VT
05482-6905
US

IV. Provider business mailing address

60 ABIGAIL DR
COLCHESTER VT
05446-3875
US

V. Phone/Fax

Practice location:
  • Phone: 802-985-8211
  • Fax: 802-985-8733
Mailing address:
  • Phone: 802-655-4240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number072-0000464
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: