Provider Demographics
NPI:1417166356
Name:PETRUZZELLO, ANTHONY A (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:A
Last Name:PETRUZZELLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 TREANOR TER
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6407
Mailing Address - Country:US
Mailing Address - Phone:561-389-4253
Mailing Address - Fax:
Practice Address - Street 1:2706 TREANOR TERRACE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-1338
Practice Address - Country:US
Practice Address - Phone:561-389-4253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4637103G00000X
NY016720-01103G00000X, 103T00000X, 103TB0200X, 103TC0700X
FLPY4637103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral