Provider Demographics
NPI:1922476605
Name:PETRUSKA, THERESA LYNN (MSW, LSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LYNN
Last Name:PETRUSKA
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1235
Mailing Address - Country:US
Mailing Address - Phone:219-718-7626
Mailing Address - Fax:
Practice Address - Street 1:4795 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2403
Practice Address - Country:US
Practice Address - Phone:219-980-6217
Practice Address - Fax:219-985-6772
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007071A253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care