Provider Demographics
NPI:1720251176
Name:PETYAK, STEFANIE E (MA, LMFT)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:E
Last Name:PETYAK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-8130
Mailing Address - Country:US
Mailing Address - Phone:980-219-2697
Mailing Address - Fax:
Practice Address - Street 1:432 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8130
Practice Address - Country:US
Practice Address - Phone:980-219-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMFT 180106H00000X
NC7052A106H00000X
NC1483106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist