Basic Information
| Provider Information | |||||||||
| NPI: | 1144511007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTY | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ORLEANS BLVD | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172782129 | ||||||||
| FaxNumber: | 5172798172 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ORLEANS BLVD | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172782129 | ||||||||
| FaxNumber: | 5172798172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401006737 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.