Provider Demographics
NPI:1568809846
Name:PETERSIK, TALYA MARIE (MS)
Entity Type:Individual
Prefix:
First Name:TALYA
Middle Name:MARIE
Last Name:PETERSIK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 N 114TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4208
Mailing Address - Country:US
Mailing Address - Phone:414-431-4444
Mailing Address - Fax:
Practice Address - Street 1:3015 N 114TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4208
Practice Address - Country:US
Practice Address - Phone:414-431-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1764-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional