Healthcare Provider Details

I. General information

NPI: 1427318369
Provider Name (Legal Business Name): GRACE E PETTY MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 OLD FOREST RD
LYNCHBURG VA
24501-2915
US

IV. Provider business mailing address

620 COURT ST
LYNCHBURG VA
24504-1312
US

V. Phone/Fax

Practice location:
  • Phone: 434-455-1000
  • Fax: 434-485-8877
Mailing address:
  • Phone: 434-455-1000
  • Fax: 434-485-8877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number64798
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005872
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: