Provider Demographics
NPI:1326409350
Name:PETELL, JERRY (LMSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:PETELL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:PETELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:10 ELIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2612
Mailing Address - Country:US
Mailing Address - Phone:518-458-9886
Mailing Address - Fax:
Practice Address - Street 1:10 ELIOT AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-2612
Practice Address - Country:US
Practice Address - Phone:518-458-9886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061436-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker