Provider Demographics
NPI:1942589098
Name:PETILLO, ELIZABETH A
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PETILLO
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 1:1 FREDERICK ABBOTT WAY
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01701-7992
Mailing Address - Country:US
Mailing Address - Phone:508-270-1364
Mailing Address - Fax:
Practice Address - Street 1:1 FREDERICK ABBOTT WAY
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-7992
Practice Address - Country:US
Practice Address - Phone:508-270-1364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health