Provider Demographics
NPI:1487963955
Name:PETTINE, DORIS ANN (OTR)
Entity type:Individual
Prefix:MS
First Name:DORIS
Middle Name:ANN
Last Name:PETTINE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 FREIDA ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-1712
Mailing Address - Country:US
Mailing Address - Phone:845-457-9039
Mailing Address - Fax:
Practice Address - Street 1:121 EXECUTIVE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5543
Practice Address - Country:US
Practice Address - Phone:914-809-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003893-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist