Provider Demographics
NPI:1659403137
Name:PETRILLA, LINDA KAY (PHD,)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:KAY
Last Name:PETRILLA
Suffix:
Gender:F
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 INDIAN RIVER BLVD
Mailing Address - Street 2:SUITE 324
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4299
Mailing Address - Country:US
Mailing Address - Phone:772-778-8252
Mailing Address - Fax:772-778-4652
Practice Address - Street 1:2770 INDIAN RIVER BLVD
Practice Address - Street 2:SUITE 324
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4299
Practice Address - Country:US
Practice Address - Phone:772-778-8252
Practice Address - Fax:772-778-4652
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2508103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75094Medicare ID - Type Unspecified