Provider Demographics
NPI:1144270422
Name:PETKOVICH, ROBIN (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:PETKOVICH
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W SMITH VALLEY RD STE A8
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1589
Mailing Address - Country:US
Mailing Address - Phone:317-750-9797
Mailing Address - Fax:
Practice Address - Street 1:1700 W SMITH VALLEY RD STE A8
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1589
Practice Address - Country:US
Practice Address - Phone:317-750-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200496030Medicaid
IN608960RRMedicare ID - Type Unspecified