Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 0248 | SD |
NPI | 1003082629 |
---|---|
Provider Name | Roni Petik |
First Address | Rapid City, SD 57709-3450 |
Second Address | Custer, SD 57730-1304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2008 |
Last Update Date | 03/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0248 | LICENSE (01) | SD |