Provider Demographics
NPI:1346014925
Name:PETSCHE PSYCHOLOGY PRACTICE, PLLC
Entity Type:Organization
Organization Name:PETSCHE PSYCHOLOGY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-344-4141
Mailing Address - Street 1:21 BRITISH AMERICAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1405
Mailing Address - Country:US
Mailing Address - Phone:518-344-4141
Mailing Address - Fax:
Practice Address - Street 1:21 BRITISH AMERICAN BLVD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1405
Practice Address - Country:US
Practice Address - Phone:518-344-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty