Provider Demographics
NPI:1770559056
Name:PETRUCCI, RALPH J (EDD)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:J
Last Name:PETRUCCI
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MEDICAL CAMPUS DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-7205
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:215-255-7825
Practice Address - Street 1:125 MEDICAL CAMPUS DR
Practice Address - Street 2:SUITE 206
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-7205
Practice Address - Country:US
Practice Address - Phone:215-233-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS0003012-L103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARO5996Medicare UPIN
PAPE089803Medicare ID - Type UnspecifiedPSYCHOLOGIST