Provider Demographics
NPI:1255403317
Name:PETITT, CHAD ALLAN (PT)
Entity type:Individual
Prefix:MR
First Name:CHAD
Middle Name:ALLAN
Last Name:PETITT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-1529
Mailing Address - Country:US
Mailing Address - Phone:712-324-0110
Mailing Address - Fax:712-324-0031
Practice Address - Street 1:301 10TH ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1529
Practice Address - Country:US
Practice Address - Phone:712-324-0110
Practice Address - Fax:712-324-0031
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0655407Medicaid
IA0803635Medicaid
IA0601260Medicaid
IA0803635Medicaid
IA16Z381Medicare Oscar/Certification
IA161381Medicare Oscar/Certification
IA160126Medicare Oscar/Certification
IA16E263Medicare ID - Type UnspecifiedLTC MEDICARE #