Individual
IVY PETRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, LCAC
Contact information
Practice address
213 MIDDLEBURY ST, GOSHEN, IN 46528
(574) 534-3300
(574) 534-5412
Mailing address
213 MIDDLEBURY ST, GOSHEN, IN 46528-2956
(574) 534-3300
(574) 534-5412
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
87001243A
IN
1041C0700X
Clinical Social Worker
Primary
34006676A
IN
Other
Enumeration date
08/12/2013
Last updated
12/31/2020
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