Provider Demographics
NPI:1447500574
Name:PETRONGOLO, MICHELLE (PSYD, BCBA)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:PETRONGOLO
Suffix:
Gender:F
Credentials:PSYD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 EGG HARBOR RD STE 302
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-9406
Mailing Address - Country:US
Mailing Address - Phone:856-278-6095
Mailing Address - Fax:866-567-5687
Practice Address - Street 1:123 EGG HARBOR RD STE 302
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-9406
Practice Address - Country:US
Practice Address - Phone:856-278-6095
Practice Address - Fax:866-567-5687
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103K00000X
MA24103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst