Provider Demographics
NPI:1922375716
Name:PETRUSKA, MIRANDA (CHAP IV)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:PETRUSKA
Suffix:
Gender:F
Credentials:CHAP IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6129
Mailing Address - Country:US
Mailing Address - Phone:360-457-0431
Mailing Address - Fax:360-457-0493
Practice Address - Street 1:118 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6129
Practice Address - Country:US
Practice Address - Phone:360-457-0431
Practice Address - Fax:360-457-0493
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDH0157Medicaid