Healthcare Provider Details

I. General information

NPI: 1881671386
Provider Name (Legal Business Name): FRED J PETRILLA JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 25TH ST
VERO BEACH FL
32960-3366
US

IV. Provider business mailing address

1903 25TH ST PO BOX 789
VERO BEACH FL
32960-3366
US

V. Phone/Fax

Practice location:
  • Phone: 772-562-0777
  • Fax: 772-770-3285
Mailing address:
  • Phone: 772-562-0777
  • Fax: 772-770-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0002507
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS33
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: