Healthcare Provider Details

I. General information

NPI: 1487530606
Provider Name (Legal Business Name): KATHERINE PETTY
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 AMADOR ST
VALLEJO CA
94590-3349
US

IV. Provider business mailing address

665 WALNUT AVE
VALLEJO CA
94592-1177
US

V. Phone/Fax

Practice location:
  • Phone: 707-556-8670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210092493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: