Provider Demographics
NPI:1194069641
Name:PETROVA, MARIYA PETROVA
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:PETROVA
Last Name:PETROVA
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 1:515 FRENCH RD
Mailing Address - Street 2:APT. 7
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5322
Mailing Address - Country:US
Mailing Address - Phone:585-754-1204
Mailing Address - Fax:
Practice Address - Street 1:175 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1059
Practice Address - Country:US
Practice Address - Phone:585-546-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-22
Last Update Date:2012-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP83791101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health