Provider Demographics
NPI:1447657135
Name:PETIT, SHAINA (PT,DPT)
Entity type:Individual
Prefix:DR
First Name:SHAINA
Middle Name:
Last Name:PETIT
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PLAIN ST E
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-1115
Mailing Address - Country:US
Mailing Address - Phone:774-218-4034
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-521-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist