Provider Demographics
NPI:1447474572
Name:CERVONI, PETRA INES (LICSW)
Entity type:Individual
Prefix:MS
First Name:PETRA
Middle Name:INES
Last Name:CERVONI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MULBERRY ST
Mailing Address - Street 2:#509
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105
Mailing Address - Country:US
Mailing Address - Phone:413-781-3163
Mailing Address - Fax:
Practice Address - Street 1:575 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-534-2627
Practice Address - Fax:413-534-2651
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107232282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital