Provider Demographics
NPI:1336110568
Name:PETROVICH, BRIAN DION (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DION
Last Name:PETROVICH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 E 4600 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4332
Mailing Address - Country:US
Mailing Address - Phone:801-505-6545
Mailing Address - Fax:
Practice Address - Street 1:1186 E 4600 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4332
Practice Address - Country:US
Practice Address - Phone:801-505-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017583103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO494703309Medicaid
MO220244625Medicare ID - Type Unspecified