MEDICARE: NATALIE JO PETROVICH, PLLC

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
1	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1649764010	OTHER	IL	PSYCHOLOGIST

General Provider Information

NPI Number	:	1154063238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATALIE JO PETROVICH, PLLC

Provider Business Mailing Address
First Line	:	939 W WASHINGTON BLVD APT 513
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2263
Country	:	US
Telephone Number	:	630-364-8306
Fax Number	:

Provider Business Practice Location Address
First Line	:	939 W WASHINGTON BLVD APT 513
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2263
Country	:	US
Telephone Number	:	630-364-8306
Fax Number	:	844-990-4167

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NATALIE JO PETROVICH
Credential	:	PSYD
Telephone Number	:	630-364-8306

Provider Enumeration Date	:	04/10/2022
Last Update Date	:	04/13/2022

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