MEDICARE: KATHERINE HELEN PETTY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	103T00000X	Psychologist	PSY.0006156	CO
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1508413311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE HELEN PETTY PHD

Provider Business Mailing Address
First Line	:	PO BOX 147
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80502-0147
Country	:	US
Telephone Number	:	720-204-8744
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 IRIS AVE STE 104
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-1998
Country	:	US
Telephone Number	:	720-204-8744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2019
Last Update Date	:	03/06/2024

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