Provider Demographics
NPI:1780184622
Name:PETROSSIAN, ANDRE (PSYD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:PETROSSIAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PASEO CAMARILLO STE 245
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6085
Mailing Address - Country:US
Mailing Address - Phone:805-988-6197
Mailing Address - Fax:
Practice Address - Street 1:1200 PASEO CAMARILLO STE 245
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6085
Practice Address - Country:US
Practice Address - Phone:805-988-6197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33886103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist