Provider Demographics
NPI:1104114750
Name:PETILLO, LISA (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:PETILLO
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MATUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LCSW
Mailing Address - Street 1:699 SACKETT ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-4561
Mailing Address - Country:US
Mailing Address - Phone:631-626-7420
Mailing Address - Fax:718-524-8340
Practice Address - Street 1:699 SACKETT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-4561
Practice Address - Country:US
Practice Address - Phone:631-626-7420
Practice Address - Fax:718-524-8340
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0767981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical