Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | 031147 | NY |
Y | 225700000X | Massage Therapist | 031147 | NY |
NPI | 1326632779 |
---|---|
Provider Name | Mary Amanda Petacchi |
First Address | Delmar, NY 12054-1135 |
Second Address | Delmar, NY 12054-1135 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/02/2021 |
Last Update Date | 25/02/2021 |