Provider Demographics
NPI:1316374036
Name:PETTA, LORENE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LORENE
Middle Name:MARIE
Last Name:PETTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4622
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-4622
Mailing Address - Country:US
Mailing Address - Phone:480-203-0403
Mailing Address - Fax:480-256-1010
Practice Address - Street 1:6424 E GREENWAY PKWY STE 100-587
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2045
Practice Address - Country:US
Practice Address - Phone:480-203-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4435103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical