Provider Demographics
NPI:1891057287
Name:SQUIRES, PETULA SHERYL-ANN (MS EDUCATION)
Entity Type:Individual
Prefix:MS
First Name:PETULA
Middle Name:SHERYL-ANN
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:MS EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 E 98TH ST
Mailing Address - Street 2:FL. 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5321
Mailing Address - Country:US
Mailing Address - Phone:929-355-7557
Mailing Address - Fax:866-679-7318
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:929-355-7557
Practice Address - Fax:866-679-7318
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist