Provider Demographics
NPI:1215718648
Name:PETRIE, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:PETRIE
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 1:6740 CROSSWINDS DR N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8606
Mailing Address - Country:US
Mailing Address - Phone:727-599-3624
Mailing Address - Fax:
Practice Address - Street 1:6740 CROSSWINDS DR N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8606
Practice Address - Country:US
Practice Address - Phone:727-599-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1490103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool