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General NPI Number Information
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NPI Number | 1134735665
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Entity Type | Individual
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Provider Name | ADRIENNE ROMAYNE PETTY LPC
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Gender | Female
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Dates
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Enumeration Date | 09/21/2020
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Last Update Date | 11/27/2023
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Provider Practice Location Address
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Address Line | 12100 OLD HALLS FERRY RD
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City | BLACK JACK
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State | MO
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Zip | 63033-7112
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Country | US
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Telephone | 314-441-6679
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Fax |
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Provider Business Mailing Address
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Address Line | 4883 BRISTOL ROCK RD
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City | BLACK JACK
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State | MO
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Zip | 63033-7104
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Country | US
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Telephone | 314-441-6679
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2017043874
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License Number State | MO
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