Healthcare Provider Details

I. General information

NPI: 1881357002
Provider Name (Legal Business Name): ZACH JAMES PETRIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 MONITOR ST
LA CROSSE WI
54603-3188
US

IV. Provider business mailing address

600 KING ST
LA CROSSE WI
54601-4389
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0001
  • Fax:
Mailing address:
  • Phone: 920-286-3321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12730125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: