Basic Information
| Provider Information | |||||||||
| NPI: | 1659419174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETIT-FRERE | ||||||||
| FirstName: | WOODSON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 956 COURT AVE | ||||||||
| Address2: | STE A138D | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1358445055 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3130 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135844505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 028857-1 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1659419174 | 05 | NY | MEDICAID |