Provider Demographics
NPI:1871706408
Name:DE GROOT, PETRA GERARDA (LCPC)
Entity type:Individual
Prefix:MS
First Name:PETRA
Middle Name:GERARDA
Last Name:DE GROOT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:PETRONELLA
Other - Middle Name:G
Other - Last Name:DEGROOT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 8388
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-8388
Mailing Address - Country:US
Mailing Address - Phone:406-728-7584
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGGINS AVE
Practice Address - Street 2:SUITE 327
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4462
Practice Address - Country:US
Practice Address - Phone:406-728-7584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT 441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT74933OtherBLUE CROSS & BLUE SHIELD