Provider Demographics
NPI:1477638542
Name:PETRY, SUELI (PHD)
Entity Type:Individual
Prefix:
First Name:SUELI
Middle Name:
Last Name:PETRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 DENISON ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2732
Mailing Address - Country:US
Mailing Address - Phone:732-565-9010
Mailing Address - Fax:732-565-0703
Practice Address - Street 1:671 HOES LN W
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-8021
Practice Address - Country:US
Practice Address - Phone:732-565-9010
Practice Address - Fax:732-565-0703
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FI00160800106H00000X
NJ35SI00447300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4144007Medicaid
NJ31-4011Medicare PIN