MEDICARE: MRS. AIDA JANETH PETRLAK LMFT

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	106H00000X	Marriage & Family Therapist	MT 1540	FL

General Provider Information

NPI Number	:	1912068719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AIDA JANETH PETRLAK LMFT

Provider Business Mailing Address
First Line	:	7508 GARFIELD ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-5328
Country	:	US
Telephone Number	:	954-986-9218
Fax Number	:

Provider Business Practice Location Address
First Line	:	1265 NW 12TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33136-2140
Country	:	US
Telephone Number	:	305-547-6827
Fax Number	:	305-547-6848

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/09/2007

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