Provider Demographics
NPI:1003190059
Name:FRED J PETRILLA JR PHD & ASSOCIATES PA
Entity Type:Organization
Organization Name:FRED J PETRILLA JR PHD & ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETRILLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:772-562-0777
Mailing Address - Street 1:1903 25TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3366
Mailing Address - Country:US
Mailing Address - Phone:772-562-0777
Mailing Address - Fax:772-770-3285
Practice Address - Street 1:1903 25TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3366
Practice Address - Country:US
Practice Address - Phone:772-562-0777
Practice Address - Fax:772-770-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002507103TC0700X
FLSS33103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75093Medicare PIN
FLFN156AMedicare PIN