Mya Petchark, LADC

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

1565 Issued in CT

Practice address

931 Bank St
New London, CT 06320-2702

Phone

(860) 574-8252

NPI assigned

May 22, 2024

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CT

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

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.

• Hartford Dispensary

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Hartford, CT
  • NPI 1104949973

  Multi-Specialty

  Medicare reassignment NPD

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

{
    "created_epoch": "1716336000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1716336000000",
    "number": "1144069840",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "359 LONG HILL RD APT 22",
            "city": "GROTON",
            "state": "CT",
            "postal_code": "063403842",
            "telephone_number": "860-389-4630"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "931 BANK ST",
            "city": "NEW LONDON",
            "state": "CT",
            "postal_code": "063202702",
            "telephone_number": "860-574-8252"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETCHARK",
        "first_name": "MYA",
        "name_prefix": "Miss",
        "credential": "LADC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2024-05-22",
        "last_updated": "2024-05-22",
        "certification_date": "2024-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "CT",
            "license": "1565",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Daniel Rudy Perkins, HS, SFIDC
• Serena Perkins
• Kayla Noel Perras, APRN
• Brianna Perry, PA-C
• Toni C Perry, LCSW
• Jana Petelle, CRNA
• Joseph W Peters, M.D.
• Deborah M. Peterson, RD, CDE
• Rene Petrone, COTA/L
• Latisha Monique Pettway, CRNA

• Addiction (Substance Use Disorder) Counselor in New London, CT
• Providers in New London, CT by specialty
• Addiction (Substance Use Disorder) Counselor in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2024; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.