Provider Demographics
NPI:1033450119
Name:PETTY, RICHARD ROSS (LCSW - R)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROSS
Last Name:PETTY
Suffix:
Gender:M
Credentials:LCSW - R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 NORTHSIDE SHOPPING CTR
Mailing Address - Street 2:GORMAN FOUNDATION OFFICE SUITE
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-4901
Mailing Address - Country:US
Mailing Address - Phone:315-363-5274
Mailing Address - Fax:315-363-4925
Practice Address - Street 1:1081 NORTHSIDE SHOPPING CTR
Practice Address - Street 2:GORMAN FOUNDATION OFFICE SUITE
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-4901
Practice Address - Country:US
Practice Address - Phone:315-363-5274
Practice Address - Fax:315-363-4925
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0759161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical