Basic Information
| Provider Information | |||||||||
| NPI: | 1609181569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRILLA | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCDC III, OCPS II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 22ND ST NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447093815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304528252 | ||||||||
| FaxNumber: | 2204524655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1341 MARKET AVE N | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447142605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304538252 | ||||||||
| FaxNumber: | 3304524655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2010 | ||||||||
| LastUpdateDate: | 08/16/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 081204 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.