Provider Demographics
NPI:1811384381
Name:PETREE, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:PETREE
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 1:9952 HYDE GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 8TH AVE W STE 200
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-5162
Practice Address - Country:US
Practice Address - Phone:941-807-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15954101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-0554413Medicaid
NC1811384381Medicaid