MEDICARE: CHRISTINE PETRIK LCSW

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
1	1041C0700X	Clinical Social Worker	R053698-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R053698-1	OTHER	NY	LISCENCE NUMBER

General Provider Information

NPI Number	:	1306055595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE PETRIK LCSW

Provider Business Mailing Address
First Line	:	410 W END AVE
Second Line	:	3B
City	:	NEW YORK
State	:	NY
Zip	:	10024-5746
Country	:	US
Telephone Number	:	212-769-1222
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 W END AVE
Second Line	:	3B
City	:	NEW YORK
State	:	NY
Zip	:	10024-5746
Country	:	US
Telephone Number	:	212-769-1222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/20/2007

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Directions to “ CHRISTINE PETRIK LCSW” Practice Location

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