Healthcare Provider Details

I. General information

NPI: 1609181569
Provider Name (Legal Business Name): KRISTEN MARIE PETRILLA LCDC III, OCPS II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1341 MARKET AVE N
CANTON OH
44714-2605
US

IV. Provider business mailing address

509 22ND ST NW
CANTON OH
44709-3815
US

V. Phone/Fax

Practice location:
  • Phone: 330-453-8252
  • Fax: 330-452-4655
Mailing address:
  • Phone: 330-452-8252
  • Fax: 220-452-4655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number081204
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: