Provider Demographics
NPI:1407114119
Name:PETRUSIK, NICOLE LYNN (BS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:PETRUSIK
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 SARVER RD
Mailing Address - Street 2:
Mailing Address - City:SARVER
Mailing Address - State:PA
Mailing Address - Zip Code:16055-9502
Mailing Address - Country:US
Mailing Address - Phone:724-256-0798
Mailing Address - Fax:
Practice Address - Street 1:5231 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1768
Practice Address - Country:US
Practice Address - Phone:412-518-7544
Practice Address - Fax:412-204-9133
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health