Provider Demographics
NPI:1093176257
Name:PETROVICK, SASHA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SASHA
Middle Name:
Last Name:PETROVICK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PARIS
Mailing Address - State:ME
Mailing Address - Zip Code:04281-6554
Mailing Address - Country:US
Mailing Address - Phone:203-733-2873
Mailing Address - Fax:
Practice Address - Street 1:24 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:MECHANIC FALLS
Practice Address - State:ME
Practice Address - Zip Code:04256-5554
Practice Address - Country:US
Practice Address - Phone:207-345-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4608101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional