Provider Demographics
NPI:1063684215
Name:PETILLO, CAROL V (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:V
Last Name:PETILLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 BOILING SPRINGS RD
Mailing Address - Street 2:STE 1400
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4205
Mailing Address - Country:US
Mailing Address - Phone:864-278-1273
Mailing Address - Fax:
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3300
Practice Address - Fax:704-295-3468
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7312231H00000X
SC3886231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1618ROtherBCBSNC
NC5939044OtherCIGNA
NC7413356Medicaid
770333OtherWELLCARE
SCP01044436OtherRAILROAD MEDICARE
NC9873230OtherAETNA
NCP01450607OtherRAILROAD MEDICARE
SC30111366OtherSELECT HEALTH OF SOUTH CAROLINA
SCSA1085Medicaid
SCSA1085Medicaid