Provider Demographics
NPI:1215681093
Name:PETROCELLI, LAURA TESTA (LMSW)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:TESTA
Last Name:PETROCELLI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MONROE DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6826
Mailing Address - Country:US
Mailing Address - Phone:716-548-0592
Mailing Address - Fax:
Practice Address - Street 1:3350 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1316
Practice Address - Country:US
Practice Address - Phone:716-835-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114691-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker