Provider Demographics
NPI:1346783826
Name:PETROVICI, MARY C (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:PETROVICI
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W RIDGE MEWS
Mailing Address - Street 2:
Mailing Address - City:WOOD RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07075-1352
Mailing Address - Country:US
Mailing Address - Phone:201-981-4770
Mailing Address - Fax:
Practice Address - Street 1:825 GEORGES RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-3357
Practice Address - Country:US
Practice Address - Phone:732-227-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-16-23831251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health