Provider Demographics
NPI:1679596290
Name:PETREY, TIMOTHY (LISW)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:PETREY
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35888 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3086
Mailing Address - Country:US
Mailing Address - Phone:440-327-1800
Mailing Address - Fax:440-327-1533
Practice Address - Street 1:35888 CENTER RIDGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3086
Practice Address - Country:US
Practice Address - Phone:440-327-1800
Practice Address - Fax:440-327-1533
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00041121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHR72229Medicare UPIN
OHSW 11362Medicare ID - Type Unspecified