Provider Demographics
NPI:1508915463
Name:PETKAC PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:PETKAC PSYCHOTHERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETKAC
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:814-882-3861
Mailing Address - Street 1:4021 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3354
Mailing Address - Country:US
Mailing Address - Phone:814-882-3861
Mailing Address - Fax:814-833-7944
Practice Address - Street 1:4021 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3354
Practice Address - Country:US
Practice Address - Phone:814-882-3861
Practice Address - Fax:814-833-7944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty