Provider Demographics
NPI:1689698631
Name:PETROSKI, JUDITH ARDEN (LSWR)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ARDEN
Last Name:PETROSKI
Suffix:
Gender:F
Credentials:LSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2329
Mailing Address - Country:US
Mailing Address - Phone:315-733-0520
Mailing Address - Fax:315-733-0518
Practice Address - Street 1:114 GENESEE ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2329
Practice Address - Country:US
Practice Address - Phone:315-733-0520
Practice Address - Fax:315-733-0518
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0561551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02562870Medicaid
NYRA9653Medicare PIN