Provider Demographics
NPI:1629560990
Name:PETRUSO, NICOLE MARIE (OTR)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PETRUSO
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 1:8826 JACKIE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1418
Mailing Address - Country:US
Mailing Address - Phone:619-992-8364
Mailing Address - Fax:
Practice Address - Street 1:8030 LA MESA BLVD # 416
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0335
Practice Address - Country:US
Practice Address - Phone:619-567-9448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26623225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics