Provider Demographics
NPI:1356019806
Name:PETRILLO, KARA
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MAUCH CHUNK ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-2065
Mailing Address - Country:US
Mailing Address - Phone:646-265-2323
Mailing Address - Fax:
Practice Address - Street 1:27 MAUCH CHUNK ST APT 2
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064-2065
Practice Address - Country:US
Practice Address - Phone:646-265-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-21-52958103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty