Provider Demographics
NPI:1215005541
Name:PETIET, CAROLE ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:ANNE
Last Name:PETIET
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 1:2340 WARD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705
Mailing Address - Country:US
Mailing Address - Phone:510-843-6760
Mailing Address - Fax:303-379-3611
Practice Address - Street 1:2340 WARD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705
Practice Address - Country:US
Practice Address - Phone:510-843-6760
Practice Address - Fax:303-379-3611
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL83110OtherBLUE CROSS BLUE SHIELD
CAPSY8311OtherBOARD OF PSYCHOLOGY
CAPSY8311OtherBOARD OF PSYCHOLOGY