Healthcare Provider Details

I. General information

NPI: 1760709646
Provider Name (Legal Business Name): MARY MARGARET PETRIE M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 E MAIN ST
DANVILLE IN
46122-9089
US

IV. Provider business mailing address

1304 PAMELA DR
FRANKLIN IN
46131-7027
US

V. Phone/Fax

Practice location:
  • Phone: 317-718-0089
  • Fax: 317-718-0097
Mailing address:
  • Phone: 317-736-8551
  • Fax: 317-736-8551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number739587
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number739587
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: