Provider Demographics
NPI:1275574071
Name:PETRELLA, DIANE MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 SEA VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-4817
Mailing Address - Country:US
Mailing Address - Phone:401-831-1341
Mailing Address - Fax:
Practice Address - Street 1:255 HOPE ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2209
Practice Address - Country:US
Practice Address - Phone:401-831-1341
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW004011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical