Provider Demographics
NPI:1114523818
Name:PETRONIS-BRANCH, MEDEA JANI (LSW, MSW, CBHCMS)
Entity Type:Individual
Prefix:
First Name:MEDEA
Middle Name:JANI
Last Name:PETRONIS-BRANCH
Suffix:
Gender:F
Credentials:LSW, MSW, CBHCMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WESTWOOD TER N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8325
Mailing Address - Country:US
Mailing Address - Phone:727-343-3662
Mailing Address - Fax:
Practice Address - Street 1:45 WESTWOOD TER N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8325
Practice Address - Country:US
Practice Address - Phone:727-343-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06967700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker