Provider Demographics
NPI:1821496936
Name:PETRIDES, JOANNA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:
Last Name:PETRIDES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E LAUREL RD STE 2100-A1
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-7020
Mailing Address - Fax:856-566-6188
Practice Address - Street 1:42 E LAUREL RD STE 2100-A1
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-7020
Practice Address - Fax:856-566-6188
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017752103T00000X, 103TC0700X
NJ35SI00553000103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0499056Medicaid
NJ0499056Medicaid