Provider Demographics
NPI:1336519255
Name:PETRY, ERICA LYNN (MA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:PETRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 HANLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8786
Mailing Address - Country:US
Mailing Address - Phone:534-544-5247
Mailing Address - Fax:534-544-5248
Practice Address - Street 1:2501 HANLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8786
Practice Address - Country:US
Practice Address - Phone:534-544-5247
Practice Address - Fax:534-544-5248
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16016-131101YA0400X
WI6017-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)