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General NPI Number Information
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NPI Number | 1558090860
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Entity Type | Individual
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Provider Name | KAITLIN M PETRILLO CLC
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Gender | Female
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Dates
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Enumeration Date | 06/10/2022
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Last Update Date | 08/22/2022
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Provider Practice Location Address
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Address Line | 18 BORMAN CT
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City | RONKONKOMA
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State | NY
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Zip | 11779-1981
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Country | US
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Telephone | 631-219-4992
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Fax |
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Provider Business Mailing Address
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Address Line | 18 BORMAN CT
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City | RONKONKOMA
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State | NY
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Zip | 11779-1981
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Country | US
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Telephone | 631-219-4992
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 341362
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number | 341362
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License Number State | NY
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