Healthcare Provider Details

I. General information

NPI: 1104042548
Provider Name (Legal Business Name): CHRISTINA M PETZEL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 10TH ST
PORT HURON MI
48060-4477
US

IV. Provider business mailing address

6549 TOWN CENTER DR STE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-3223
  • Fax: 833-329-6632
Mailing address:
  • Phone: 800-395-3223
  • Fax: 833-329-6632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401009035
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: