Individual
MARLA VIVIAN PETRIK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3425 13TH ST, BAKER CITY, OR 97814-1340
(541) 523-7400
(541) 523-4927
Mailing address
3425 13TH ST, BAKER CITY, OR 97814-1340
(541) 523-7400
(541) 523-4927
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
24-QMHA-R-6147
OR
172V00000X
Community Health Worker
106768
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2672690
ODL
OR
05
—
500809171
—
OR
Enumeration date
06/25/2019
Last updated
11/07/2024
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