Provider Demographics
NPI:1275006652
Name:PETRAKOVICH, ARIEL KAITLYN
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:KAITLYN
Last Name:PETRAKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6505 SHILOH ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:770-754-0085
Mailing Address - Fax:770-754-9288
Practice Address - Street 1:6505 SHILOH ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005
Practice Address - Country:US
Practice Address - Phone:770-754-0085
Practice Address - Fax:770-754-9288
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-10-03
Deactivation Date:2019-09-23
Deactivation Code:
Reactivation Date:2019-10-03
Provider Licenses
StateLicense IDTaxonomies
1-19-38197103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician