Provider Demographics
NPI:1245662295
Name:PETRUCCI, RISA (MA)
Entity type:Individual
Prefix:MRS
First Name:RISA
Middle Name:
Last Name:PETRUCCI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 UPLAND DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1425
Mailing Address - Country:US
Mailing Address - Phone:631-757-8964
Mailing Address - Fax:
Practice Address - Street 1:99 HOLLYWOOD DR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3135
Practice Address - Country:US
Practice Address - Phone:631-366-2982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY670572121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist