Brenda L Petticrew, LMT
Individual provider Active NPI Specialist · Shannon, IL
NPI 1568810331 · NPPES record last updated Jun 2, 2016
Key facts
- NPI
- 1568810331
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Specialist 174400000X
- License
- 227.016348 (IL)
- Practice address
- 409 S Hickory St
Shannon, IL 61078-9017 - Phone
- (815) 238-2588
- NPI assigned
- Jun 2, 2016
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 227.016348 | IL | MD | Specialist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 227.016348 | IL | Yes |
Addresses
Primary practice location
409 S Hickory St
Shannon, IL 61078-9017
Mailing address
409 S Hickory St
Shannon, IL 61078-9017
Phone (815) 238-2588
Other providers in Shannon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 2, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.