Provider Demographics
NPI:1801301981
Name:PETINO, DAMIAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:
Last Name:PETINO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07849-2468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 VALLEY RD STE 104
Practice Address - Street 2:
Practice Address - City:MT ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07856-1320
Practice Address - Country:US
Practice Address - Phone:732-841-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00545300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ35SI00545300OtherNJ DIVISION OF CONSUMER AFFAIRS - PSYCHOLOGY LICENSE