Provider Demographics
NPI:1275187080
Name:PETROSKY, THERESA ELIZABETH (LCPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ELIZABETH
Last Name:PETROSKY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ELIZABETH
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11036 FOLKSTONE DR # OK
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8050
Mailing Address - Country:US
Mailing Address - Phone:405-922-6695
Mailing Address - Fax:
Practice Address - Street 1:35 MILES ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10200101YM0800X
MECC6723101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health