Shannon Dexter Petrovich, LCSW, LISAC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

LCSW-4024 Issued in AZ

Practice address

5855 N Kolb Rd Unit 4208
Tucson, AZ 85750-0991

Phone

(520) 909-4740

NPI assigned

Sep 19, 2016

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in AZ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 1988

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Aleph Center, P.L.L.C.Group PAC ID 0143209809, 13 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Aleph Center, P.L.L.C.

  • Psychiatry Physician
  • Tucson, AZ
  • NPI 1215022157

  AZ

  Medicare reassignment Care Compare group NPD
• Honu Counseling PLLC

  • Community/Behavioral Health Agency
  • Tucson, AZ
  • NPI 1962858936
  NPD (past) Authorized official
• In Balance Counseling Inc

  • Community/Behavioral Health Agency
  • Tucson, AZ
  • NPI 1205986171
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1474243200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1474243200000",
    "number": "1104374255",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5855 N KOLB RD UNIT 4208",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857500991",
            "telephone_number": "520-909-4740"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5855 N KOLB RD UNIT 4208",
            "city": "TUCSON",
            "state": "AZ",
            "postal_code": "857500991",
            "telephone_number": "520-909-4740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETROVICH",
        "first_name": "SHANNON",
        "middle_name": "DEXTER",
        "credential": "LCSW, LISAC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2016-09-19",
        "last_updated": "2016-09-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "AZ",
            "license": "LISAC-1365",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "AZ",
            "license": "LCSW-4024",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Christina Carol Petrin
• Christopher Jay Petro, M.D.
• Kiley Petro
• Celeste Styczynski Petronella, M.S., CCC-SLP
• Richard M Petronella, MD
• Edward P. Petrow Jr., DO
• Emily Marie Petry
• Philip Gary Pettett, MD
• Susan Petti, ED.S., NCSP
• Nancy Joyce Pettibon, CRNFA

• All providers in Tucson, AZ
• Clinical Social Worker in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.