Provider Demographics
NPI:1881671386
Name:PETRILLA, FRED J JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:PETRILLA
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 25TH ST
Mailing Address - Street 2:PO BOX 789
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3366
Mailing Address - Country:US
Mailing Address - Phone:772-562-0777
Mailing Address - Fax:772-770-3285
Practice Address - Street 1:1903 25TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3366
Practice Address - Country:US
Practice Address - Phone:772-562-0777
Practice Address - Fax:772-770-3285
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002507103TC0700X
FLSS33103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
75093Medicare ID - Type Unspecified
FLFN158ZMedicare PIN