Provider Demographics
NPI:1205246055
Name:PETROWSKI, ALYSSA CHRISTINE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CHRISTINE
Last Name:PETROWSKI
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:CHRISTINE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-454-9759
Practice Address - Street 1:4126 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4123
Practice Address - Country:US
Practice Address - Phone:812-645-2308
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11314712103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-13-14712OtherBCBA CERTIFICATE
1-13-14712OtherBCBA
1-13-14712OtherBCBA CERTIFICATION