Provider Demographics
NPI:1609865989
Name:PETEK, THOMAS C (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:PETEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33516 9TH AVE S
Mailing Address - Street 2:BLDG 1
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6322
Mailing Address - Country:US
Mailing Address - Phone:253-838-2501
Mailing Address - Fax:253-838-1354
Practice Address - Street 1:33516 9TH AVE S
Practice Address - Street 2:BLDG 1
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6322
Practice Address - Country:US
Practice Address - Phone:253-838-2501
Practice Address - Fax:253-838-1354
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000502103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7005663Medicaid
R10811Medicare UPIN