Healthcare Provider Details

I. General information

NPI: 1194778894
Provider Name (Legal Business Name): LEONORA K PETTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 S 8TH ST
BEAUMONT TX
77701-7719
US

IV. Provider business mailing address

2750 S 8TH ST
BEAUMONT TX
77701-7719
US

V. Phone/Fax

Practice location:
  • Phone: 409-839-1000
  • Fax:
Mailing address:
  • Phone: 409-839-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20578
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD035524L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberP6242
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: