Provider Demographics
NPI:1437013794
Name:UDEH, PETRA
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:UDEH
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 1:13598 N INTERSTATE 35
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2624
Mailing Address - Country:US
Mailing Address - Phone:855-374-4900
Mailing Address - Fax:855-322-3694
Practice Address - Street 1:12758 CIMARRON PATH STE 127
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3498
Practice Address - Country:US
Practice Address - Phone:855-374-4900
Practice Address - Fax:855-322-3694
Is Sole Proprietor?:No
Enumeration Date:2025-12-11
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-25-452137106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician