Provider Demographics
NPI:1417005885
Name:PETRASH, MARIAN ELIZABETH (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:ELIZABETH
Last Name:PETRASH
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:MILWANKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:971-206-5140
Mailing Address - Fax:971-206-5209
Practice Address - Street 1:CONSONUS REHAB SERVICES
Practice Address - Street 2:4560 SE INTERNATIONAL WAY
Practice Address - City:MILWANKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5140
Practice Address - Fax:971-206-5209
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR114460107599235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist