Provider Demographics
NPI:1023341518
Name:CHRISTINE R PETRO, PSY.D., LLC
Entity type:Organization
Organization Name:CHRISTINE R PETRO, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSY.D.
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PETRO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-785-2545
Mailing Address - Street 1:69 GRAYSON NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1363
Mailing Address - Country:US
Mailing Address - Phone:770-785-2545
Mailing Address - Fax:
Practice Address - Street 1:69 GRAYSON NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017
Practice Address - Country:US
Practice Address - Phone:770-785-2545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003011103TB0200X, 103TC0700X, 103TF0000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA668652382CMedicaid
GA668652382EMedicaid