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General NPI Number Information
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NPI Number | 1356366504
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Entity Type | Individual
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Provider Name | GARY LEON PETTY PHD
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Gender | Male
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 03/13/2009
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Provider Practice Location Address
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Address Line | 1118 BARKDULL ST
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City | HOUSTON
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State | TX
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Zip | 77006-6402
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Country | US
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Telephone | 281-447-0847
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Fax |
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Provider Business Mailing Address
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Address Line | 1815 BISSONNET ST
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City | HOUSTON
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State | TX
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Zip | 77005-1711
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Country | US
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Telephone | 281-447-0847
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Fax | 713-589-9631
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 21753
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License Number State | TX
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