MEDICARE: PETRA PLACE COUNSELING SERVICES

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	1041C0700X	Clinical Social Worker	081629	NY

General Provider Information

NPI Number	:	1386057222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETRA PLACE COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	888 LONG POND RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-1111
Country	:	US
Telephone Number	:	585-730-7777
Fax Number	:	585-730-7779

Provider Business Practice Location Address
First Line	:	888 LONG POND RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-1111
Country	:	US
Telephone Number	:	585-730-7777
Fax Number	:	585-730-7779

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. STACEY M REED-MACGREGOR
Credential	:	MSW LMSW
Telephone Number	:	585-730-7777

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/09/2014

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