Provider Demographics
NPI:1639181548
Name:PETROVICH, ANDREA (LPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WOODBINE PLACE
Mailing Address - Street 2:#775
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608
Mailing Address - Country:US
Mailing Address - Phone:903-757-8194
Mailing Address - Fax:903-757-8294
Practice Address - Street 1:107 WOODBINE PLACE
Practice Address - Street 2:#775
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75608
Practice Address - Country:US
Practice Address - Phone:903-757-8194
Practice Address - Fax:903-757-8294
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6732101YM0800X
TX66633-TX101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL761879400Medicaid