Provider Demographics
NPI:1891952339
Name:PETOK, CAROL (PHD, LCPC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:PETOK
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S WASHINGTON ST
Mailing Address - Street 2:#1006
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4351
Mailing Address - Country:US
Mailing Address - Phone:410-770-5813
Mailing Address - Fax:410-770-5813
Practice Address - Street 1:770 PORT ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-8102
Practice Address - Country:US
Practice Address - Phone:410-819-3395
Practice Address - Fax:410-770-5813
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD774800100Medicaid