Provider Demographics
NPI:1104402866
Name:PETROVIC, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PETROVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 PEBBLE RIDGE CIR APT 152
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-6531
Mailing Address - Country:US
Mailing Address - Phone:701-793-9792
Mailing Address - Fax:
Practice Address - Street 1:7382 HALITE CT
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-3023
Practice Address - Country:US
Practice Address - Phone:720-899-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1144936857Medicaid
CO1154022614Medicaid