Most Relevant Information
Provider Data
| NPI Number: | 1003422049 |
| Provider Name: | TARA LEE PETROCHKO LCSW |
| Entity Type: | Individual |
| Taxonomy Code: | 1041C0700X |
| Specialty: | Social Worker |
| License Number: | 096265 |
Most Important Dates
| Enumeration Date: | 09/16/2020 |
| Last Updated: | 10/10/2023 |
Provider Practice Location
322 8TH AVE
NEW YORK
NY
100018001
Practice Location Phone/Fax
| Phone: | 2122832830 |
| Fax: |
Provider Mailing Location
138 E 112TH ST APT 2D
NEW YORK
NY
100292670
Provider Mailing Phone/Fax
| Phone: | 6462811679 |
| Fax: |