Provider Demographics
NPI:1922003458
Name:PETROCCI, THEO A (LPC)
Entity Type:Individual
Prefix:MR
First Name:THEO
Middle Name:A
Last Name:PETROCCI
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 GROVE AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-2220
Mailing Address - Country:US
Mailing Address - Phone:804-822-0271
Mailing Address - Fax:804-353-3939
Practice Address - Street 1:16 WALNUT AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4719
Practice Address - Country:US
Practice Address - Phone:540-345-6468
Practice Address - Fax:540-345-3204
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701000926101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005401437Medicaid