Provider Demographics
NPI:1770567935
Name:PETRIE, JANICE J (LCSW)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:J
Last Name:PETRIE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JETTA
Other - Middle Name:
Other - Last Name:PETRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-1005
Mailing Address - Country:US
Mailing Address - Phone:307-634-9653
Mailing Address - Fax:307-638-8256
Practice Address - Street 1:2526 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3159
Practice Address - Country:US
Practice Address - Phone:307-634-9653
Practice Address - Fax:307-638-8256
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4661041C0700X
CO1526331041C0700X
MA1117871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20146Medicare ID - Type Unspecified