Provider Demographics
NPI:1902016348
Name:PETRUS PSYCHOLOGY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PETRUS PSYCHOLOGY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-496-6180
Mailing Address - Street 1:3625 E THOUSAND OAKS BLVD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3626
Mailing Address - Country:US
Mailing Address - Phone:805-496-6180
Mailing Address - Fax:
Practice Address - Street 1:3625 E THOUSAND OAKS BLVD
Practice Address - Street 2:SUITE 135
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-3626
Practice Address - Country:US
Practice Address - Phone:805-496-6180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17390103TC0700X
CAPSY19903103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty