Provider Demographics
NPI:1538789953
Name:PETTIT, WILLIAM (PTA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PETTIT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E 10TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-3243
Mailing Address - Country:US
Mailing Address - Phone:719-629-6633
Mailing Address - Fax:
Practice Address - Street 1:8055 E TUFTS AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-2835
Practice Address - Country:US
Practice Address - Phone:303-247-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013079225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant