Provider Demographics
NPI:1447313028
Name:PETRIE, RAYNETTE PEARL (LCSW)
Entity type:Individual
Prefix:
First Name:RAYNETTE
Middle Name:PEARL
Last Name:PETRIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:2337 3RD AVE N
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1625
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-250241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010144572OtherBLUE SHIELD
IDL6063OtherBLUE CROSS OF IDAHO
ID000010017772OtherREGENCE BLUE CROSS
IDL3126OtherBLUE CROSS
IDL6063OtherBLUE CROSS OF IDAHO