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General NPI Number Information
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NPI Number | 1447077615
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Entity Type | Organization
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Legal Business Name | MARY PETRO LCSW PLLC
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Dates
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Enumeration Date | 09/20/2024
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Last Update Date | 09/20/2024
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Provider Practice Location Address
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Address Line | 415 S MULFORD RD
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City | ROCKFORD
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State | IL
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Zip | 61108-3011
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Country | US
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Telephone | 779-910-5001
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Fax | 815-399-5767
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Provider Business Mailing Address
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Address Line | 11166 FYVIE CT
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City | BELVIDERE
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State | IL
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Zip | 61008-7408
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Country | US
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Telephone | 779-910-5001
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MARY M PETRO
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Credential | LCSW
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Telephone | 779-910-5001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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