Provider Demographics
NPI:1861180051
Name:PETROVSKI, CLAY WESLEY
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:WESLEY
Last Name:PETROVSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:OCEAN PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98640-1330
Mailing Address - Country:US
Mailing Address - Phone:360-619-2316
Mailing Address - Fax:
Practice Address - Street 1:2107 162ND LN
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-6621
Practice Address - Country:US
Practice Address - Phone:360-619-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist