Provider Demographics
NPI:1942862693
Name:PETROVICH, MADALYN MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:MADALYN
Middle Name:MARIE
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N OAKHURST DR APT 105
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3913
Mailing Address - Country:US
Mailing Address - Phone:203-770-8293
Mailing Address - Fax:
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 405
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7655
Practice Address - Country:US
Practice Address - Phone:310-234-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist