Provider Demographics
NPI:1417152273
Name:PETROLLE, ELIZABETH JEAN (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JEAN
Last Name:PETROLLE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MRS
Other - First Name:ELIZABETH JEAN
Other - Middle Name:PETERS
Other - Last Name:PETROLLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:5229 NEW DESIGN RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7103
Mailing Address - Country:US
Mailing Address - Phone:301-668-1320
Mailing Address - Fax:301-696-1390
Practice Address - Street 1:5229 NEW DESIGN RD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7103
Practice Address - Country:US
Practice Address - Phone:301-668-1320
Practice Address - Fax:301-696-1390
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical