Provider Demographics
NPI:1861774127
Name:PETHTEL, MEGAN BROOKE (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:BROOKE
Last Name:PETHTEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-599-2515
Mailing Address - Fax:304-285-3738
Practice Address - Street 1:1228 COUNTRY CLUB ROAD, #15
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2369
Practice Address - Country:US
Practice Address - Phone:304-366-0461
Practice Address - Fax:304-366-0497
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV1573225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant