Provider Demographics
NPI:1437217221
Name:PETRELLA, VICTOR J (RNCS)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:J
Last Name:PETRELLA
Suffix:
Gender:M
Credentials:RNCS
Other - Prefix:
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Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:PRIMARY CARE OUTREACH TEAM
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4109
Mailing Address - Country:US
Mailing Address - Phone:413-447-2617
Mailing Address - Fax:413-447-2176
Practice Address - Street 1:FAIRVIEW COMMONS
Practice Address - Street 2:151 CHRISTIAN HILL ROAD
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230
Practice Address - Country:US
Practice Address - Phone:413-528-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA162890364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult