Provider Demographics
NPI:1841963634
Name:PETRILLO, NICOLE ROSE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:PETRILLO
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6577 S DAHLIA CIR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-3501
Mailing Address - Country:US
Mailing Address - Phone:914-419-3783
Mailing Address - Fax:
Practice Address - Street 1:5760 E OTERO AVE
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-3064
Practice Address - Country:US
Practice Address - Phone:914-419-3783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-19-36971103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst