Provider Demographics
NPI:1083846653
Name:PETTY, SANDRA KAY (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:PETTY
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:JEFFCOAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:1013 RIVERBURCH PKWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8887
Mailing Address - Country:US
Mailing Address - Phone:866-261-8090
Mailing Address - Fax:706-226-7869
Practice Address - Street 1:1013 RIVERBURCH PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8887
Practice Address - Country:US
Practice Address - Phone:866-261-8090
Practice Address - Fax:706-226-7869
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006241235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist