Provider Demographics
NPI:1538461124
Name:PETRUCELLI, NICHOLAS JOEL (CAC III)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOEL
Last Name:PETRUCELLI
Suffix:
Gender:M
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-4714
Mailing Address - Country:US
Mailing Address - Phone:303-468-6191
Mailing Address - Fax:303-321-3556
Practice Address - Street 1:7251 E 49TH AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-4714
Practice Address - Country:US
Practice Address - Phone:303-468-6191
Practice Address - Fax:303-321-3556
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)