Provider Demographics
NPI:1013049998
Name:PETRILLO, SUSAN JANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JANE
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9706
Mailing Address - Country:US
Mailing Address - Phone:585-786-3665
Mailing Address - Fax:
Practice Address - Street 1:39 DUNCAN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1017
Practice Address - Country:US
Practice Address - Phone:585-786-0190
Practice Address - Fax:585-786-0196
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0377631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical