Provider Demographics
NPI:1609181569
Name:PETRILLA, KRISTEN MARIE (LCDC III, OCPS II)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:MARIE
Last Name:PETRILLA
Suffix:
Gender:F
Credentials:LCDC III, OCPS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 22ND ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3815
Mailing Address - Country:US
Mailing Address - Phone:330-452-8252
Mailing Address - Fax:220-452-4655
Practice Address - Street 1:1341 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2605
Practice Address - Country:US
Practice Address - Phone:330-453-8252
Practice Address - Fax:330-452-4655
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081204101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)