Provider Demographics
NPI:1366594830
Name:PETTIFORD, DINA NAOMI (MS, CCC-A)
Entity type:Individual
Prefix:MRS
First Name:DINA
Middle Name:NAOMI
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 HALTON RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-2229
Mailing Address - Country:US
Mailing Address - Phone:315-299-4327
Mailing Address - Fax:
Practice Address - Street 1:5700 W GENESEE ST
Practice Address - Street 2:SUITE 229
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3200
Practice Address - Country:US
Practice Address - Phone:315-234-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY624694231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist