Provider Demographics
NPI:1548656523
Name:KELLY PETRINO, PSYD
Entity type:Organization
Organization Name:KELLY PETRINO, PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRINO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:307-460-0781
Mailing Address - Street 1:507 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3753
Mailing Address - Country:US
Mailing Address - Phone:307-460-0781
Mailing Address - Fax:307-742-4089
Practice Address - Street 1:507 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3753
Practice Address - Country:US
Practice Address - Phone:307-460-0781
Practice Address - Fax:307-742-4089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY505103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY151943Medicaid
WY151943Medicaid