Provider Demographics
NPI:1528187804
Name:PETRIE, CAMERON DEAN (MA)
Entity Type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:DEAN
Last Name:PETRIE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 E AVENUE R2
Mailing Address - Street 2:
Mailing Address - City:LITTLEROCK
Mailing Address - State:CA
Mailing Address - Zip Code:93543-1405
Mailing Address - Country:US
Mailing Address - Phone:661-944-8961
Mailing Address - Fax:
Practice Address - Street 1:921 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49556106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist