Provider Demographics
NPI:1508985896
Name:PETRELLA, TINAMARIE (MS, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:TINAMARIE
Middle Name:
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-3214
Mailing Address - Country:US
Mailing Address - Phone:508-339-8298
Mailing Address - Fax:
Practice Address - Street 1:550 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-1735
Practice Address - Country:US
Practice Address - Phone:508-222-3053
Practice Address - Fax:508-222-8084
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA393231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAD0078OtherBCBS#
MAAD0078OtherBCBS#