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NPI Code Detail

MEDICARE: KRISTINE A PETLICK

MEDICARE: KRISTINE A PETLICK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist6301013815MI
2103T00000XPsychologist6361005132MI

General Provider Information

NPI Number : 1144499864
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTINE A PETLICK
Provider Business Mailing Address
First Line : 5675 FAIRVIEW ST
Second Line :
City : STEVENSVILLE
State : MI
Zip : 49127-1033
Country : US
Telephone Number : 269-429-7727
Fax Number : 269-429-5754
Provider Business Practice Location Address
First Line : 5675 FAIRVIEW ST
Second Line :
City : STEVENSVILLE
State : MI
Zip : 49127-1033
Country : US
Telephone Number : 269-429-7727
Fax Number : 269-429-5754
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2008
Last Update Date : 01/13/2025

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Directions to “ KRISTINE A PETLICK ” Practice Location

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