Provider Demographics
NPI:1689304511
Name:PETRELLI, CARRIE (LCSW)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
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 1:1803 E BASSWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1809
Mailing Address - Country:US
Mailing Address - Phone:773-620-0128
Mailing Address - Fax:
Practice Address - Street 1:1803 E BASSWOOD LN
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1809
Practice Address - Country:US
Practice Address - Phone:773-620-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490243321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical