Provider Demographics
NPI:1598832842
Name:PETZ, MICHAELA MIRKOVICH (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:MIRKOVICH
Last Name:PETZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:ANNE
Other - Last Name:MIRKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1133 RAILROAD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5054
Mailing Address - Country:US
Mailing Address - Phone:360-676-2164
Mailing Address - Fax:
Practice Address - Street 1:1133 RAILROAD AVE STE 100
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5054
Practice Address - Country:US
Practice Address - Phone:360-676-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00050552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health