Provider Demographics
NPI:1396227401
Name:PETTY, MAGGIE MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:MARIE
Last Name:PETTY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 HIGH HOUSE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3510
Mailing Address - Country:US
Mailing Address - Phone:919-388-0111
Mailing Address - Fax:919-388-8668
Practice Address - Street 1:4140 RAMSEY ST STE 110
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-7658
Practice Address - Country:US
Practice Address - Phone:910-920-4903
Practice Address - Fax:910-920-4910
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP11905225100000X
TN11905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446631Medicaid