Provider Demographics
NPI:1114366614
Name:PETTIT, GARY COURTLAND (BA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:COURTLAND
Last Name:PETTIT
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 FRANCES AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34949-3559
Mailing Address - Country:US
Mailing Address - Phone:772-519-9197
Mailing Address - Fax:
Practice Address - Street 1:1616 FRANCES AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34949-3559
Practice Address - Country:US
Practice Address - Phone:772-519-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator