Basic Information
| Provider Information | |||||||||
| NPI: | 1093759334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETELICKI | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 SHEPHERD DR | ||||||||
| Address2: | |||||||||
| City: | WANAQUE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074651017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732486216 | ||||||||
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| Practice Location | |||||||||
| Address1: | 242 W PARKWAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | POMPTON PLAINS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074441029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738310717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01023900 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.