Provider Demographics
NPI:1700217759
Name:PETRUS, EMILY MARIE (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:MARIE
Last Name:PETRUS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:MARIE
Other - Last Name:KUNTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, LCSW
Mailing Address - Street 1:28 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1405
Mailing Address - Country:US
Mailing Address - Phone:315-287-2811
Mailing Address - Fax:
Practice Address - Street 1:28 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1405
Practice Address - Country:US
Practice Address - Phone:315-287-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089822104100000X
NY085870-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker