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General NPI Number Information
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NPI Number | 1861784068
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Entity Type | Individual
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Provider Name | KELLY PETRINO PSY.D
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Gender | Female
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Dates
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Enumeration Date | 05/05/2011
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Last Update Date | 05/11/2022
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Provider Practice Location Address
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Address Line | 3350 W AMERICANA TER STE 210
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City | BOISE
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State | ID
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Zip | 83706-2546
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Country | US
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Telephone | 406-880-5568
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Fax |
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Provider Business Mailing Address
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Address Line | 3883 S COMO AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-1446
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Country | US
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Telephone | 406-880-5568
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 18071
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 505
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License Number State | WY
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 203518
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License Number State | ID
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