Provider Demographics
NPI:1710642962
Name:TABUSO PETOSKY, DAMIENNE HUGENA AUGUSTA
Entity Type:Individual
Prefix:MS
First Name:DAMIENNE
Middle Name:HUGENA AUGUSTA
Last Name:TABUSO PETOSKY
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 1:301 SMITH DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 SMITH DR STE 3
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-4131
Practice Address - Country:US
Practice Address - Phone:724-779-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)