Provider Demographics
NPI:1396801254
Name:PETRIDES, MICHAEL WILLIAM (MS(R), ABD, LPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:PETRIDES
Suffix:
Gender:M
Credentials:MS(R), ABD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5836
Mailing Address - Country:US
Mailing Address - Phone:860-889-8346
Mailing Address - Fax:860-889-2658
Practice Address - Street 1:331 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5836
Practice Address - Country:US
Practice Address - Phone:860-889-8346
Practice Address - Fax:860-889-2658
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000430101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional