Provider Demographics
NPI:1407304470
Name:PETRILL, AMY LOUISE (LISW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:PETRILL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19016 TURKEY MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-6449
Mailing Address - Country:US
Mailing Address - Phone:440-570-7755
Mailing Address - Fax:
Practice Address - Street 1:4018 MEDINA RD STE D
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9675
Practice Address - Country:US
Practice Address - Phone:330-722-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2002101104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2488428Medicaid