Provider Demographics
NPI:1265567507
Name:PETCOFF, TANYA MARIE (LLP, MA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:PETCOFF
Suffix:
Gender:F
Credentials:LLP, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3402
Mailing Address - Country:US
Mailing Address - Phone:248-219-5909
Mailing Address - Fax:
Practice Address - Street 1:33493 W 14 MILE RD STE 130
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1587
Practice Address - Country:US
Practice Address - Phone:248-851-5437
Practice Address - Fax:248-592-1378
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012794103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical