Provider Demographics
NPI:1730873043
Name:PETRICKO, MCKENZI
Entity type:Individual
Prefix:
First Name:MCKENZI
Middle Name:
Last Name:PETRICKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 AVENUE B STE A
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4333
Mailing Address - Country:US
Mailing Address - Phone:308-633-7878
Mailing Address - Fax:308-633-7018
Practice Address - Street 1:3510 AVENUE B STE A
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4333
Practice Address - Country:US
Practice Address - Phone:308-633-7878
Practice Address - Fax:308-633-7018
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist