Healthcare Provider Details

I. General information

NPI: 1730021775
Provider Name (Legal Business Name): HOLLY PETTET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 BALDWIN AVE
DEFUNIAK SPRINGS FL
32435-2593
US

IV. Provider business mailing address

152 THIS WAY
FREEPORT FL
32439-5435
US

V. Phone/Fax

Practice location:
  • Phone: 850-684-5739
  • Fax:
Mailing address:
  • Phone: 850-684-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP00776
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS2001
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: