Provider Demographics
NPI:1316053853
Name:PETRAK, KATHLEEN M (LPC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:PETRAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 APRIL POINT DR N
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-5816
Mailing Address - Country:US
Mailing Address - Phone:936-588-6823
Mailing Address - Fax:
Practice Address - Street 1:704 LONGMIRE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1850
Practice Address - Country:US
Practice Address - Phone:936-441-2500
Practice Address - Fax:936-539-2515
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15429101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84053LOtherBCBS