Provider Demographics
NPI:1184995250
Name:PETROELJE, MARK ROBERT (MA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:PETROELJE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W DIVERSEY PKWY
Mailing Address - Street 2:SUITE 275
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1879
Mailing Address - Country:US
Mailing Address - Phone:312-502-9014
Mailing Address - Fax:
Practice Address - Street 1:1000 W DIVERSEY PKWY
Practice Address - Street 2:SUITE 275
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1879
Practice Address - Country:US
Practice Address - Phone:312-502-9014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-22
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008805101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional