Provider Demographics
NPI:1114493368
Name:PETRAKOVITZ, CHELSEA LIANE (DPT)
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LIANE
Last Name:PETRAKOVITZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:LIANE
Other - Last Name:VADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:5800 FOLKS RD
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:MI
Mailing Address - Zip Code:49246-9632
Mailing Address - Country:US
Mailing Address - Phone:517-745-7685
Mailing Address - Fax:
Practice Address - Street 1:900 COOPER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3398
Practice Address - Country:US
Practice Address - Phone:517-780-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist