Provider Demographics
NPI:1518124635
Name:PETRASEK, MICHAEL WILLIAM (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:PETRASEK
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 CHIPPEWA RD
Mailing Address - Street 2:SUITE # 213
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-2316
Mailing Address - Country:US
Mailing Address - Phone:440-546-0454
Mailing Address - Fax:
Practice Address - Street 1:7650 CHIPPEWA RD
Practice Address - Street 2:SUITE # 213
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-2316
Practice Address - Country:US
Practice Address - Phone:440-546-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3538103T00000X
CO3101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist