Provider Demographics
NPI:1114528627
Name:PETROLLA, JOSEPH MICHAEL
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:PETROLLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3296 STONES THROW AVE
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4213
Mailing Address - Country:US
Mailing Address - Phone:330-757-3166
Mailing Address - Fax:
Practice Address - Street 1:3296 STONES THROW AVE
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-4213
Practice Address - Country:US
Practice Address - Phone:330-757-3166
Practice Address - Fax:330-757-4234
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist