Provider Demographics
NPI:1962934513
Name:PETROCCI, KIM (MED)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PETROCCI
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8525 FRIENDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-9706
Mailing Address - Country:US
Mailing Address - Phone:330-302-0320
Mailing Address - Fax:
Practice Address - Street 1:8525 FRIENDSVILLE RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-9706
Practice Address - Country:US
Practice Address - Phone:330-302-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1169907103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool