Provider Demographics
NPI:1942694278
Name:PETTKO, DIANE MARY (MS, LCADC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARY
Last Name:PETTKO
Suffix:
Gender:F
Credentials:MS, LCADC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARY
Other - Last Name:FAUVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-1158
Mailing Address - Country:US
Mailing Address - Phone:410-535-3079
Mailing Address - Fax:410-535-2220
Practice Address - Street 1:280 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3582
Practice Address - Country:US
Practice Address - Phone:410-535-3079
Practice Address - Fax:410-535-2220
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)