Provider Demographics
NPI:1356023105
Name:PETHTEL, MEGAN (PSYD)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PETHTEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:MILLIKAN-PETHTEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:8258 ASTORIA CIR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-2778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2415 UNIVERSITY PKWY STE 219
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2809
Practice Address - Country:US
Practice Address - Phone:800-687-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12354103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist