Provider Demographics
NPI:1003173295
Name:PETTY, JOY BIRDWELL (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOY
Middle Name:BIRDWELL
Last Name:PETTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2347
Mailing Address - Country:US
Mailing Address - Phone:225-658-7751
Mailing Address - Fax:225-658-7753
Practice Address - Street 1:1219 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2347
Practice Address - Country:US
Practice Address - Phone:225-658-7751
Practice Address - Fax:225-658-7753
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3D123CD22Medicare PIN