Provider Demographics
NPI:1861789273
Name:PETRIE, REBECCA ANNE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANNE
Last Name:PETRIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:ANNE
Other - Last Name:NORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:339 OLD TOWN RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3450
Mailing Address - Country:US
Mailing Address - Phone:631-828-8157
Mailing Address - Fax:
Practice Address - Street 1:339 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3450
Practice Address - Country:US
Practice Address - Phone:631-828-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0697581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical