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General NPI Number Information
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NPI Number | 1023341518
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Entity Type | Organization
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Legal Business Name | CHRISTINE R PETRO, PSY.D., LLC
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Dates
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Enumeration Date | 09/15/2009
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Last Update Date | 06/08/2018
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Provider Practice Location Address
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Address Line | 69 GRAYSON NEW HOPE RD
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City | GRAYSON
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State | GA
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Zip | 30017
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Country | US
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Telephone | 770-785-2545
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Fax |
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Provider Business Mailing Address
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Address Line | 69 GRAYSON NEW HOPE RD
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City | GRAYSON
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State | GA
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Zip | 30017-1363
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Country | US
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Telephone | 770-785-2545
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Fax |
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Authorized Official
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Title or Position | PSY.D.
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Name | CHRISTINE RENEE PETRO
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Credential | PSY.D.
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Telephone | 770-785-2545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | PSY003011
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY003011
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number | PSY003011
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY003011
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License Number State | GA
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