Provider Demographics
NPI:1922100189
Name:PETUCHOWSKI, SILVIA RITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SILVIA
Middle Name:RITA
Last Name:PETUCHOWSKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CLARK RD
Mailing Address - Street 2:NUMBER 1
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6030
Mailing Address - Country:US
Mailing Address - Phone:617-739-2256
Mailing Address - Fax:
Practice Address - Street 1:62 CLARK RD
Practice Address - Street 2:NUMBER 1
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-6030
Practice Address - Country:US
Practice Address - Phone:617-739-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7315103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1202715Medicaid
MA1202715Medicaid