Provider Demographics
NPI:1144069840
Name:PETCHARK, MYA (LADC)
Entity type:Individual
Prefix:MISS
First Name:MYA
Middle Name:
Last Name:PETCHARK
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 LONG HILL RD APT 22
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3842
Mailing Address - Country:US
Mailing Address - Phone:860-389-4630
Mailing Address - Fax:
Practice Address - Street 1:931 BANK ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2702
Practice Address - Country:US
Practice Address - Phone:860-574-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1565101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty