Provider Demographics
NPI:1588015614
Name:PETROVICH, SVETLANA (LICSW)
Entity type:Individual
Prefix:MS
First Name:SVETLANA
Middle Name:
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 14TH AVE S APT 102
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2240
Mailing Address - Country:US
Mailing Address - Phone:612-986-9505
Mailing Address - Fax:
Practice Address - Street 1:3201 14TH AVE S APT 102
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2240
Practice Address - Country:US
Practice Address - Phone:612-986-9505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN224921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical