Provider Demographics
NPI:1679144257
Name:PETRICH, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PETRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 N PUGET SOUND AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1509 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4568
Practice Address - Country:US
Practice Address - Phone:360-736-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist