Provider Demographics
NPI:1982134755
Name:PETRULSKY, MAURA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:ELIZABETH
Last Name:PETRULSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 WELLINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:LAURYS STATION
Mailing Address - State:PA
Mailing Address - Zip Code:18059-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:940 NE JENSEN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4704
Practice Address - Country:US
Practice Address - Phone:772-334-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist