Provider Demographics
NPI:1770739724
Name:PETRIK, AMANDA R (LCPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:PETRIK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 SW 29TH ST
Mailing Address - Street 2:STE. 214
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2078
Mailing Address - Country:US
Mailing Address - Phone:785-477-9117
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 29TH ST
Practice Address - Street 2:STE. 214
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-2078
Practice Address - Country:US
Practice Address - Phone:785-477-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCPC2245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200569610BMedicaid