Provider Demographics
NPI:1205107612
Name:PETRICCA, ANN MARIE
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:PETRICCA
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 1:36 PUBLIC SQ STE 105
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7864
Mailing Address - Country:US
Mailing Address - Phone:404-884-0814
Mailing Address - Fax:
Practice Address - Street 1:36 PUBLIC SQ STE 105
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7864
Practice Address - Country:US
Practice Address - Phone:440-488-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-16
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1100475101YP2500X
OHC.1100475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health