Provider Demographics
NPI:1477381713
Name:PETRICH, NICOLE BETH (LPC, LPC-MH, ACS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:BETH
Last Name:PETRICH
Suffix:
Gender:F
Credentials:LPC, LPC-MH, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9419
Mailing Address - Fax:
Practice Address - Street 1:4405 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4187
Practice Address - Country:US
Practice Address - Phone:605-328-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7132101YP2500X
SDLPC-MH30508101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional