Provider Demographics
NPI:1417922097
Name:PETTA, MARLENE FRANCES (MSSA ACSW LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:FRANCES
Last Name:PETTA
Suffix:
Gender:F
Credentials:MSSA ACSW LMSW
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:FRANCES
Other - Last Name:BALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSA ACSW CSW
Mailing Address - Street 1:380 CROWN MILL DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9436
Mailing Address - Country:US
Mailing Address - Phone:706-364-7954
Mailing Address - Fax:706-364-7954
Practice Address - Street 1:380 CROWN MILL DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9436
Practice Address - Country:US
Practice Address - Phone:706-364-7954
Practice Address - Fax:706-364-7954
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL760944104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152167OtherCIGNA
S19926Medicare UPIN