Provider Demographics
NPI:1194096016
Name:PETRULIS, AMY JACQUELIN (MS, LCSW)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:JACQUELIN
Last Name:PETRULIS
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-1925
Mailing Address - Country:US
Mailing Address - Phone:406-223-2092
Mailing Address - Fax:406-823-6305
Practice Address - Street 1:108 1/2 W CALLENDER ST APT 4
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-2647
Practice Address - Country:US
Practice Address - Phone:406-223-2092
Practice Address - Fax:406-823-6305
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical