MEDICARE: MS. KRISTEN M PETRILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1295957447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTEN M PETRILLO

Provider Business Mailing Address
First Line	:	2520 N WASHTENAW AVE
Second Line	:	FIRST FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60647-1816
Country	:	US
Telephone Number	:	773-513-7720
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 N WASHTENAW AVE
Second Line	:	FIRST FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60647-1816
Country	:	US
Telephone Number	:	773-513-7720
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	06/10/2009

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