Provider Demographics
NPI:1407380850
Name:PETTY, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6628 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-5390
Mailing Address - Country:US
Mailing Address - Phone:702-409-1346
Mailing Address - Fax:
Practice Address - Street 1:6628 BEACON RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-5390
Practice Address - Country:US
Practice Address - Phone:702-409-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation