Provider Demographics
NPI:1982417598
Name:PETTRY, CYRIZ S
Entity type:Individual
Prefix:
First Name:CYRIZ
Middle Name:S
Last Name:PETTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CELESTE
Other - Middle Name:S
Other - Last Name:PETTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1075 CREEKSIDE RIDGE DR STE 280
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3504
Mailing Address - Country:US
Mailing Address - Phone:916-729-3098
Mailing Address - Fax:
Practice Address - Street 1:1075 CREEKSIDE RIDGE DR STE 280
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3504
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician