Provider Demographics
NPI:1922102201
Name:PETRISKO, MARY LOUISE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:LOUISE
Last Name:PETRISKO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 PHYSICIANS CT
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4031
Mailing Address - Country:US
Mailing Address - Phone:812-491-7739
Mailing Address - Fax:812-491-8095
Practice Address - Street 1:6221 PHYSICIANS CT
Practice Address - Street 2:SUITE 2
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4031
Practice Address - Country:US
Practice Address - Phone:812-491-7739
Practice Address - Fax:812-491-8095
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003567A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000301641OtherANTHEM BCBS