Provider Demographics
NPI:1073208518
Name:PETTY, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 ADDA AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-8715
Mailing Address - Country:US
Mailing Address - Phone:614-446-7484
Mailing Address - Fax:614-665-6061
Practice Address - Street 1:253 N STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-1471
Practice Address - Country:US
Practice Address - Phone:614-446-7484
Practice Address - Fax:614-665-6061
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.013560225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist