Provider Demographics
NPI:1124093554
Name:PETROSINO, MARIA M (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:M
Last Name:PETROSINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6546
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-6546
Mailing Address - Country:US
Mailing Address - Phone:949-365-0309
Mailing Address - Fax:949-831-2439
Practice Address - Street 1:30101 TOWN CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5006
Practice Address - Country:US
Practice Address - Phone:949-365-0309
Practice Address - Fax:949-831-2439
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR16753Medicare UPIN
CACP13776AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER