Provider Demographics
NPI:1093590135
Name:PETITT, ANDREA SHEREE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:SHEREE
Last Name:PETITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7724 58TH PL N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3233
Mailing Address - Country:US
Mailing Address - Phone:507-215-6851
Mailing Address - Fax:
Practice Address - Street 1:6701 PARKWAY CIR STE 300
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2849
Practice Address - Country:US
Practice Address - Phone:507-215-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician