Provider Demographics
NPI:1437605342
Name:PETTIT, MELINDA KAY
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:KAY
Last Name:PETTIT
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 1:104 JORDAN PLAZA BLVD
Mailing Address - Street 2:SUITE 402-403
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-2055
Mailing Address - Country:US
Mailing Address - Phone:903-581-9472
Mailing Address - Fax:
Practice Address - Street 1:104 JORDAN PLAZA BLVD
Practice Address - Street 2:SUITE 402-403
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-2055
Practice Address - Country:US
Practice Address - Phone:903-581-9472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12348101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12348OtherLCDC