Provider Demographics
NPI:1790409613
Name:DEPETRIS, TANYA
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:DEPETRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 DODSON MILL RD
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-9372
Mailing Address - Country:US
Mailing Address - Phone:336-755-8470
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9305
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health