Provider Demographics
NPI:1306334263
Name:PETRASH, CIARA RAYNE
Entity type:Individual
Prefix:
First Name:CIARA
Middle Name:RAYNE
Last Name:PETRASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CIARA
Other - Middle Name:RAYNE
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16111 OLD FOREST PT APT 100
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6189 LEHMAN DR STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5409
Practice Address - Country:US
Practice Address - Phone:719-266-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician