Basic Information
| Provider Information | |||||||||
| NPI: | 1760797898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRE | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| OtherLastName: | PETRE | ||||||||
| OtherFirstName: | DALE | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1116 WAVERLY DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618215011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173590559 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 AVENUE C | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618325410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174423200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149-005478 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.