MEDICARE: DR. FRED J PETRILLA JR. PHD

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	103TC0700X	Clinical Psychologist	PY0002507	FL
2	103TS0200X	School Psychologist	SS33	FL

General Provider Information

NPI Number	:	1881671386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FRED J PETRILLA JR. PHD

Provider Business Mailing Address
First Line	:	1903 25TH ST
Second Line	:	PO BOX 789
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3366
Country	:	US
Telephone Number	:	772-562-0777
Fax Number	:	772-770-3285

Provider Business Practice Location Address
First Line	:	1903 25TH ST
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3366
Country	:	US
Telephone Number	:	772-562-0777
Fax Number	:	772-770-3285

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

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	12/08/2011

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