Healthcare Provider Details

I. General information

NPI: 1225530645
Provider Name (Legal Business Name): MEAGAN R PETTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FULTON AVE
CINCINNATI OH
45206-2504
US

IV. Provider business mailing address

3715 ANIOTON CT
CINCINNATI OH
45227-1001
US

V. Phone/Fax

Practice location:
  • Phone: 513-961-4663
  • Fax: 513-961-4681
Mailing address:
  • Phone: 513-570-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number138
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.163123
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: