Provider Demographics
NPI:1447077615
Name:MARY PETRO LCSW PLLC
Entity type:Organization
Organization Name:MARY PETRO LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:779-910-5001
Mailing Address - Street 1:11166 FYVIE CT
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7408
Mailing Address - Country:US
Mailing Address - Phone:779-910-5001
Mailing Address - Fax:
Practice Address - Street 1:415 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3011
Practice Address - Country:US
Practice Address - Phone:779-910-5001
Practice Address - Fax:815-399-5767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty