Provider Demographics
NPI:1922806967
Name:PETRIK, KATHERINE THERESA
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:THERESA
Last Name:PETRIK
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 1:801 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5723
Mailing Address - Country:US
Mailing Address - Phone:218-415-1304
Mailing Address - Fax:
Practice Address - Street 1:5675 26TH AVE S STE 140
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8975
Practice Address - Country:US
Practice Address - Phone:701-658-5883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND21153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist