Healthcare Provider Details

I. General information

NPI: 1770567935
Provider Name (Legal Business Name): JANICE J PETRIE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: JETTA PETRIE LCSW

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 SEYMOUR AVE
CHEYENNE WY
82001-3159
US

IV. Provider business mailing address

PO BOX 1005
CHEYENNE WY
82003-1005
US

V. Phone/Fax

Practice location:
  • Phone: 307-634-9653
  • Fax: 307-638-8256
Mailing address:
  • Phone: 307-634-9653
  • Fax: 307-638-8256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number466
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number152633
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111787
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: