Provider Demographics
NPI:1457485591
Name:PETRAK, MICHELLE R (PHD, CCC-A)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:R
Last Name:PETRAK
Suffix:
Gender:F
Credentials:PHD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 W CENTRAL RD STE 4300
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2381
Mailing Address - Country:US
Mailing Address - Phone:847-392-2250
Mailing Address - Fax:847-392-2204
Practice Address - Street 1:880 W CENTRAL RD STE 4300
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2381
Practice Address - Country:US
Practice Address - Phone:847-392-2250
Practice Address - Fax:847-392-2204
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000787231H00000X, 231HA2400X, 231HA2500X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL630720Medicare ID - Type UnspecifiedMEDICARE INDIV. PROV. NO.