Provider Demographics
NPI:1023452067
Name:PETKUS, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PETKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 KENMORE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-4338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 KENMORE ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801
Practice Address - Country:US
Practice Address - Phone:540-251-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007185101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114281870OtherNPI