Provider Demographics
NPI:1710438882
Name:PETRIE, REBECCA (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:JAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:7 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2501
Mailing Address - Country:US
Mailing Address - Phone:607-758-6100
Mailing Address - Fax:
Practice Address - Street 1:7 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2501
Practice Address - Country:US
Practice Address - Phone:607-758-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid