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General NPI Number Information
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NPI Number | 1548656523
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Entity Type | Organization
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Legal Business Name | KELLY PETRINO, PSYD
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 04/07/2015
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Provider Practice Location Address
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Address Line | 507 S 4TH ST
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City | LARAMIE
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State | WY
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Zip | 82070-3753
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Country | US
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Telephone | 307-460-0781
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Fax | 307-742-4089
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Provider Business Mailing Address
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Address Line | 507 S 4TH ST
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City | LARAMIE
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State | WY
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Zip | 82070-3753
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Country | US
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Telephone | 307-460-0781
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Fax | 307-742-4089
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | DR. KELLY PETRINO
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Credential | PSYD
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Telephone | 307-460-0781
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 505
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License Number State | WY
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