Provider Demographics
NPI:1093849697
Name:PETRELLA, REGINA M
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:PETRELLA
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 1:6 KIKI PL
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-4645
Mailing Address - Country:US
Mailing Address - Phone:310-962-4330
Mailing Address - Fax:310-454-9174
Practice Address - Street 1:110 N MACLAY AVE STE 109
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340
Practice Address - Country:US
Practice Address - Phone:310-962-4330
Practice Address - Fax:310-454-9174
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40767106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist