Provider Demographics
NPI:1457649899
Name:PETRUSICH, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:PETRUSICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:887 POTRERO AVE
Practice Address - Street 2:L-UNIT
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2869
Practice Address - Country:US
Practice Address - Phone:415-206-6346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor