MEDICARE: GRETCHEN PETTINICO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	6403	CT

General Provider Information

NPI Number	:	1063602712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN PETTINICO PT

Provider Business Mailing Address
First Line	:	1389 W MAIN ST STE 225
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3115
Country	:	US
Telephone Number	:	203-757-1474
Fax Number	:	203-757-1474

Provider Business Practice Location Address
First Line	:	1389 W MAIN ST STE 225
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06708-3115
Country	:	US
Telephone Number	:	203-757-1474
Fax Number	:	203-757-1474

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/30/2007

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