MEDICARE: MR. DENNIS GUY PETTY LCSW

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	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1437236601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS GUY PETTY LCSW

Provider Business Mailing Address
First Line	:	1124 S 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2406
Country	:	US
Telephone Number	:	217-523-3143
Fax Number	:	217-523-7695

Provider Business Practice Location Address
First Line	:	1124 S 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2406
Country	:	US
Telephone Number	:	217-523-3143
Fax Number	:	217-523-7695

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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