Provider Demographics
NPI:1275629099
Name:HEATH, EDITH PETRELLO (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:PETRELLO
Last Name:HEATH
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 1:400 NORTH STREET
Mailing Address - Street 2:PO BOX 562
Mailing Address - City:NORFOLK
Mailing Address - State:CT
Mailing Address - Zip Code:06058-0562
Mailing Address - Country:US
Mailing Address - Phone:860-542-6941
Mailing Address - Fax:860-542-5096
Practice Address - Street 1:400 NORTH STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:CT
Practice Address - Zip Code:06058-0562
Practice Address - Country:US
Practice Address - Phone:860-542-6941
Practice Address - Fax:860-542-5096
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT307568OtherMHN
CT060000738CT02OtherANTHEM
CT680001237Medicare ID - Type Unspecified