Provider Demographics
NPI:1497293492
Name:PETRUCHA, STEPHANIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:PETRUCHA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NORTH BATH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740
Mailing Address - Country:US
Mailing Address - Phone:732-923-5226
Mailing Address - Fax:732-923-5277
Practice Address - Street 1:75 N BATH AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6317
Practice Address - Country:US
Practice Address - Phone:732-923-5226
Practice Address - Fax:732-923-5277
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055577001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical