Provider Demographics
NPI:1962627448
Name:PETRELLA-SHIPMAN, TERRA MARIE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:MARIE
Last Name:PETRELLA-SHIPMAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HEMLOCK AVE
Mailing Address - Street 2:#A
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-8233
Mailing Address - Country:US
Mailing Address - Phone:760-720-1393
Mailing Address - Fax:
Practice Address - Street 1:6994 EL CAMINO REAL
Practice Address - Street 2:SUITE 205-B
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-4116
Practice Address - Country:US
Practice Address - Phone:760-331-3862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42006106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist