Individual
MISS MYA PETCHARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LADC
Contact information
Practice address
931 BANK ST, NEW LONDON, CT 06320-2702
(860) 574-8252
Mailing address
359 LONG HILL RD APT 22, GROTON, CT 06340-3842
(860) 389-4630
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1565
CT
Other
Enumeration date
05/22/2024
Last updated
05/22/2024
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