Provider Demographics
NPI:1427016880
Name:PETTY, TYRUS C JR (LSCSW)
Entity Type:Individual
Prefix:MR
First Name:TYRUS
Middle Name:C
Last Name:PETTY
Suffix:JR
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5847 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-2462
Mailing Address - Country:US
Mailing Address - Phone:785-273-7292
Mailing Address - Fax:785-273-1201
Practice Address - Street 1:5847 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614-2462
Practice Address - Country:US
Practice Address - Phone:785-273-7292
Practice Address - Fax:785-273-1201
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS044600Medicare ID - Type Unspecified