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General NPI Number Information
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NPI Number | 1174134001
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Entity Type | Individual
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Provider Name | BRANDON PETTRY
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Gender | Male
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Dates
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Enumeration Date | 08/13/2020
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 508 DICKSON ST STE 2
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City | WELLINGTON
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State | OH
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Zip | 44090-1300
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Country | US
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Telephone | 440-828-0012
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Fax |
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Provider Business Mailing Address
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Address Line | 29454 HAWLEY RD
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City | SULLIVAN
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State | OH
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Zip | 44880-9602
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Country | US
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Telephone | 440-731-9030
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | C.2103628
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License Number State | OH
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