Provider Demographics
NPI:1760797898
Name:PETRE, DALE R
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:R
Last Name:PETRE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DALE
Other - Middle Name:R
Other - Last Name:PETRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1116 WAVERLY DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-5011
Mailing Address - Country:US
Mailing Address - Phone:217-359-0559
Mailing Address - Fax:
Practice Address - Street 1:210 AVENUE C
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5410
Practice Address - Country:US
Practice Address - Phone:217-442-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0054781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical