Provider Demographics
NPI:1558191049
Name:PETRILLE, MEGHAN CARY
Entity type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:CARY
Last Name:PETRILLE
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 1:11057 EL NOPAL
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2204
Mailing Address - Country:US
Mailing Address - Phone:619-721-6855
Mailing Address - Fax:
Practice Address - Street 1:4750 DATE AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9214
Practice Address - Country:US
Practice Address - Phone:619-668-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1094731041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool