Provider Demographics
NPI:1851553028
Name:PETRONKO, MICHAEL ROMAN
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROMAN
Last Name:PETRONKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LINDEN AVE
Mailing Address - Street 2:SUITE 205-A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1834
Mailing Address - Country:US
Mailing Address - Phone:973-258-1515
Mailing Address - Fax:
Practice Address - Street 1:26 LINDEN AVE
Practice Address - Street 2:SUITE 205-A
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1834
Practice Address - Country:US
Practice Address - Phone:973-258-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical