Provider Demographics
NPI:1124391669
Name:PETROSIAN, SERGE (CADC II)
Entity Type:Individual
Prefix:
First Name:SERGE
Middle Name:
Last Name:PETROSIAN
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E ELMWOOD AVE
Mailing Address - Street 2:APT. O
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2587
Mailing Address - Country:US
Mailing Address - Phone:818-804-6520
Mailing Address - Fax:
Practice Address - Street 1:5930 S MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1201
Practice Address - Country:US
Practice Address - Phone:818-551-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7121111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)