MEDICARE: GARY LEON PETTY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	21753	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356366504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY LEON PETTY PHD

Provider Business Mailing Address
First Line	:	1815 BISSONNET ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1711
Country	:	US
Telephone Number	:	281-447-0847
Fax Number	:	713-589-9631

Provider Business Practice Location Address
First Line	:	1118 BARKDULL ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-6402
Country	:	US
Telephone Number	:	281-447-0847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	03/13/2009

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Directions to “ GARY LEON PETTY PHD” Practice Location

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