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NPI Code Detail

MEDICARE: MRS. JANET LEE PETTY MA, LPC, CCDP-D

MEDICARE: MRS. JANET LEE PETTY MA, LPC, CCDP-D
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
1101YA0400XAddiction (Substance Use Disorder) Counselor3770MO
2101YP2500XProfessional Counselor2008037617MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12008037617OTHERMODIVISON OF PROFESSIONAL REGISTRATION, COMMITTEE FOR PROFESSIONAL COUNSELORS

General Provider Information

NPI Number : 1528361037
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JANET LEE PETTY MA, LPC, CCDP-D
Provider Business Mailing Address
First Line : 203 N GRAND ST
Second Line : P.O. BOX 429
City : SALEM
State : MO
Zip : 65560-1344
Country : US
Telephone Number : 573-729-4103
Fax Number : 573-729-4420
Provider Business Practice Location Address
First Line : 203 N GRAND ST
Second Line :
City : SALEM
State : MO
Zip : 65560-1344
Country : US
Telephone Number : 573-729-4103
Fax Number : 573-729-4420
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2010
Last Update Date : 09/18/2017

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