Provider Demographics
NPI:1770136236
Name:PETRONELLA, RICK
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:PETRONELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HUNTCLIFF STE 1210
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-1809
Mailing Address - Country:US
Mailing Address - Phone:678-395-7922
Mailing Address - Fax:678-954-6589
Practice Address - Street 1:1010 HUNTCLIFF STE 1210
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-1809
Practice Address - Country:US
Practice Address - Phone:678-395-7922
Practice Address - Fax:678-954-6589
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0079101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)