Healthcare Provider Details

I. General information

NPI: 1285470625
Provider Name (Legal Business Name): DANA PETROSEVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 07/05/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 CENTRE ST
BROCKTON MA
02302-2733
US

IV. Provider business mailing address

180 CENTRE ST
BROCKTON MA
02302-2733
US

V. Phone/Fax

Practice location:
  • Phone: 508-586-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN2368090
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN2368090
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: