Healthcare Provider Details

I. General information

NPI: 1114830742
Provider Name (Legal Business Name): LAUREN E PETTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29887 W 11 MILE RD
FARMINGTON HILLS MI
48336-1309
US

IV. Provider business mailing address

29887 W 11 MILE RD
FARMINGTON HILLS MI
48336-1309
US

V. Phone/Fax

Practice location:
  • Phone: 248-474-4701
  • Fax:
Mailing address:
  • Phone: 248-474-4701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451025336
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: