Provider Demographics
NPI:1194030635
Name:PETTY, BRYN (SLP)
Entity Type:Individual
Prefix:
First Name:BRYN
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 TEAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-3518
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:2211 I 35 SOUTH
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741
Practice Address - Country:US
Practice Address - Phone:512-394-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX676535Medicare UPIN
TX456606Medicare UPIN