Provider Demographics
NPI:1316694094
Name:PETRO, CAROL LOUISE (LSW)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LOUISE
Last Name:PETRO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11565 PEARL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-3356
Mailing Address - Country:US
Mailing Address - Phone:440-846-0862
Mailing Address - Fax:440-846-0890
Practice Address - Street 1:11565 PEARL RD STE 200
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-3356
Practice Address - Country:US
Practice Address - Phone:440-846-0862
Practice Address - Fax:440-846-0890
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.00313171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0162191Medicaid