Provider Demographics
NPI:1861784068
Name:PETRINO, KELLY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:PETRINO
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 1:3883 S COMO AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1446
Mailing Address - Country:US
Mailing Address - Phone:406-880-5568
Mailing Address - Fax:
Practice Address - Street 1:3350 W AMERICANA TER STE 210
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2546
Practice Address - Country:US
Practice Address - Phone:406-880-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18071101YM0800X
WY505103T00000X
ID203518103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist