Provider Demographics
NPI:1538244561
Name:PETREY, THOMAS P (LCSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:PETREY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10305 MEMORY LANE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8815
Mailing Address - Country:US
Mailing Address - Phone:804-257-9321
Mailing Address - Fax:804-748-9098
Practice Address - Street 1:10305 MEMORY LANE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-8815
Practice Address - Country:US
Practice Address - Phone:804-257-9321
Practice Address - Fax:804-748-9098
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040015211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010006082Medicaid
VA010006082Medicaid