Provider Demographics
NPI:1104141746
Name:PETRELLA, JOLENE PATRICIA
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:PATRICIA
Last Name:PETRELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NEW KING ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-1205
Mailing Address - Country:US
Mailing Address - Phone:914-390-9880
Mailing Address - Fax:914-390-9881
Practice Address - Street 1:10 NEW KING ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-1205
Practice Address - Country:US
Practice Address - Phone:914-390-9880
Practice Address - Fax:914-390-9881
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019868-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist