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NPI Code Detail

MEDICARE: DIANE MARY PETTKO MS, LCADC

MEDICARE: DIANE MARY PETTKO MS, LCADC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1942694278
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIANE MARY PETTKO MS, LCADC
Provider Business Mailing Address
First Line : PO BOX 1158
Second Line :
City : PRINCE FREDERICK
State : MD
Zip : 20678-1158
Country : US
Telephone Number : 410-535-3079
Fax Number : 410-535-2220
Provider Business Practice Location Address
First Line : 280 STAFFORD RD
Second Line :
City : PRINCE FREDERICK
State : MD
Zip : 20678-3582
Country : US
Telephone Number : 410-535-3079
Fax Number : 410-535-2220
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2015
Last Update Date : 11/29/2022

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