Provider Demographics
NPI:1265432843
Name:PETKAC, JOHN S (MA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:PETKAC
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 1:4021 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3354
Mailing Address - Country:US
Mailing Address - Phone:814-882-3861
Mailing Address - Fax:814-833-7944
Practice Address - Street 1:4021 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3354
Practice Address - Country:US
Practice Address - Phone:814-882-3861
Practice Address - Fax:814-833-7944
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002741101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional