Provider Demographics
NPI:1356651475
Name:PETRELLESE, MARY A C (BSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A C
Last Name:PETRELLESE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MAIN ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-3040
Mailing Address - Country:US
Mailing Address - Phone:203-743-4412
Mailing Address - Fax:203-744-3500
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:SUITE 503
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-3040
Practice Address - Country:US
Practice Address - Phone:203-743-4412
Practice Address - Fax:203-744-3500
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003522Medicaid