MEDICARE: HOLLY PETTET

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	103TS0200X	School Psychologist	SP00776	OH
2	103TS0200X	School Psychologist	SS2001	FL

General Provider Information

NPI Number	:	1730021775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY PETTET

Provider Business Mailing Address
First Line	:	152 THIS WAY
Second Line	:
City	:	FREEPORT
State	:	FL
Zip	:	32439-5435
Country	:	US
Telephone Number	:	850-684-5739
Fax Number	:

Provider Business Practice Location Address
First Line	:	640 BALDWIN AVE
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32435-2593
Country	:	US
Telephone Number	:	850-684-5739
Fax Number	:

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

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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Directions to “ HOLLY PETTET ” Practice Location

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