Provider Demographics
NPI:1184213498
Name:PETRUZZELLA, ANTONIO (PHD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:PETRUZZELLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:PETRUZZELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:110 N FEDERAL HWY APT 505
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1182
Mailing Address - Country:US
Mailing Address - Phone:201-805-5112
Mailing Address - Fax:
Practice Address - Street 1:805 E BROWARD BLVD STE 301
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2046
Practice Address - Country:US
Practice Address - Phone:954-300-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11566103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLGYFUOtherFLORIDA BLUE