Provider Demographics
NPI:1235764325
Name:PETRISKI, LAUREN ELIZABETH (MS, CAS)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:PETRISKI
Suffix:
Gender:F
Credentials:MS, CAS
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:KITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CAS
Mailing Address - Street 1:32 DIAMOND RD
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-5907
Mailing Address - Country:US
Mailing Address - Phone:907-203-0208
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-1636
Practice Address - Country:US
Practice Address - Phone:845-458-8661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2545527103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool