MEDICARE: JEAN-RALPH PETIDO LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	014622	NY

General Provider Information

NPI Number	:	1508611625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN-RALPH PETIDO LMHC

Provider Business Mailing Address
First Line	:	43 UNDERHILL RD APT 4
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-9445
Country	:	US
Telephone Number	:	845-480-4131
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 WILSON PL FL 2
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10550-2602
Country	:	US
Telephone Number	:	914-668-9124
Fax Number	:	914-668-0940

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2024
Last Update Date	:	05/02/2024

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