Provider Demographics
NPI:1467076000
Name:PETROVIC, ELEXA RENEE
Entity Type:Individual
Prefix:
First Name:ELEXA
Middle Name:RENEE
Last Name:PETROVIC
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 1:606 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2052
Mailing Address - Country:US
Mailing Address - Phone:440-465-0121
Mailing Address - Fax:
Practice Address - Street 1:136 TRADEWIND RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16102-2705
Practice Address - Country:US
Practice Address - Phone:855-400-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-19-40235103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst