Provider Demographics
NPI:1073378311
Name:PETRY, LORI ANN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:PETRY
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 1:1504 C AND O DAM RD
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9649
Mailing Address - Country:US
Mailing Address - Phone:304-254-4812
Mailing Address - Fax:
Practice Address - Street 1:25 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3664
Practice Address - Country:US
Practice Address - Phone:304-255-7526
Practice Address - Fax:304-252-2329
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2934101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health