Provider Demographics
NPI:1588385686
Name:DEPETRO, EMILY ELIZABETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ELIZABETH
Last Name:DEPETRO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-1704
Mailing Address - Country:US
Mailing Address - Phone:906-869-8003
Mailing Address - Fax:
Practice Address - Street 1:112 W WASHINGTON ST STE D
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4367
Practice Address - Country:US
Practice Address - Phone:906-869-8003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6351004440103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical