Provider Demographics
NPI:1629290234
Name:PETRELLI, TAMARA S (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:PETRELLI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 PINE TREE LN
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7836
Mailing Address - Country:US
Mailing Address - Phone:561-662-6900
Mailing Address - Fax:
Practice Address - Street 1:1645 PALM BEACH LAKES BLVD STE 1200
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2214
Practice Address - Country:US
Practice Address - Phone:561-662-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 2130104100000X
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker