Healthcare Provider Details

I. General information

NPI: 1174690309
Provider Name (Legal Business Name): PETERSBURG MENTAL HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTH NORDIC DRIVE
PETERSBURG AK
99833-1309
US

IV. Provider business mailing address

PO BOX 1309
PETERSBURG AK
99833-1309
US

V. Phone/Fax

Practice location:
  • Phone: 907-772-3332
  • Fax: 888-858-8850
Mailing address:
  • Phone: 907-772-3332
  • Fax: 888-858-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number282463
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number282463
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number282463
License Number StateAK

VIII. Authorized Official

Name: SUSAN OHMER
Title or Position: DIRECTOR
Credential: LCSW
Phone: 907-772-3332