Provider Demographics
NPI:1235804618
Name:PETTY, PEYTON ROSE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:ROSE
Last Name:PETTY
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:PEYTON
Other - Middle Name:ROSE
Other - Last Name:CONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:1320 CRIMSON LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6285
Mailing Address - Country:US
Mailing Address - Phone:574-807-1158
Mailing Address - Fax:
Practice Address - Street 1:3120 SUITE B WINDSOR COURT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514
Practice Address - Country:US
Practice Address - Phone:170-085-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008990A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN33008990AOtherLICENSE NUMBER