Provider Demographics
NPI:1750553533
Name:BRIAN D. PETROVICH, PSYD, LPC, LLC
Entity type:Organization
Organization Name:BRIAN D. PETROVICH, PSYD, LPC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-678-5532
Mailing Address - Street 1:308 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-1518
Mailing Address - Country:US
Mailing Address - Phone:417-678-5532
Mailing Address - Fax:417-678-6242
Practice Address - Street 1:308 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-1518
Practice Address - Country:US
Practice Address - Phone:417-678-5532
Practice Address - Fax:417-678-6242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220244625Medicare PIN
MOY37529Medicare UPIN