Provider Demographics
NPI:1366869612
Name:MCINTOSH, PETROVNIA FERNANDE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PETROVNIA
Middle Name:FERNANDE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 GRAND TETON PLZ
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1047
Mailing Address - Country:US
Mailing Address - Phone:608-827-7220
Mailing Address - Fax:608-827-7223
Practice Address - Street 1:6502 GRAND TETON PLZ
Practice Address - Street 2:SUITE 102
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1047
Practice Address - Country:US
Practice Address - Phone:608-827-7220
Practice Address - Fax:608-827-7223
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8317-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical