Provider Demographics
NPI:1558090860
Name:PETRILLO, KAITLIN M (CLC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BORMAN CT
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1981
Mailing Address - Country:US
Mailing Address - Phone:631-219-4992
Mailing Address - Fax:
Practice Address - Street 1:18 BORMAN CT
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-1981
Practice Address - Country:US
Practice Address - Phone:631-219-4992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA341362101Y00000X
NY341362174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty