MEDICARE: SARA MARIE PETTIT BCBA

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	103K00000X	Behavior Analyst	1-20-44432	CT

General Provider Information

NPI Number	:	1346817228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA MARIE PETTIT BCBA

Provider Business Mailing Address
First Line	:	PO BOX 1004
Second Line	:
City	:	BETHEL
State	:	CT
Zip	:	06801-6004
Country	:	US
Telephone Number	:	860-946-0362
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 STONY HILL RD LOWR LEVEL
Second Line	:
City	:	BETHEL
State	:	CT
Zip	:	06801-1166
Country	:	US
Telephone Number	:	860-946-0362
Fax Number	:

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

Provider Enumeration Date	:	06/08/2021
Last Update Date	:	06/08/2021

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