Provider Demographics
NPI:1104374255
Name:PETROVICH, SHANNON DEXTER (LCSW, LISAC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEXTER
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:LCSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 N KOLB RD UNIT 4208
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-0991
Mailing Address - Country:US
Mailing Address - Phone:520-909-4740
Mailing Address - Fax:
Practice Address - Street 1:5855 N KOLB RD UNIT 4208
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-0991
Practice Address - Country:US
Practice Address - Phone:520-909-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1365101YA0400X
AZLCSW-40241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)