1497883235 NPI number — MRS. MELINDA PETERS PETRICH MACCCSLP

Table of content: MRS. MELINDA PETERS PETRICH MACCCSLP (NPI 1497883235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497883235 NPI number — MRS. MELINDA PETERS PETRICH MACCCSLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRICH
Provider First Name:
MELINDA
Provider Middle Name:
PETERS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MACCCSLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497883235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1358 CRAIGVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15243-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-276-6865
Provider Business Mailing Address Fax Number:
412-276-6865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3394 SAXONBURG BLVD
Provider Second Line Business Practice Location Address:
SUITE 620
Provider Business Practice Location Address City Name:
GLENSHAW
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15116-3168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-767-5967
Provider Business Practice Location Address Fax Number:
412-767-5960
Provider Enumeration Date:
03/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SL007271 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101638115 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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