Provider Demographics
NPI:1477909455
Name:PETTY, JANICE (LPC, LSATP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPC, LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1306
Mailing Address - Country:US
Mailing Address - Phone:571-354-0338
Mailing Address - Fax:571-386-2663
Practice Address - Street 1:4660 KENMORE AVE STE 701
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:571-354-0338
Practice Address - Fax:571-386-2663
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000324101YA0400X
VA0701006463101YP2500X
VA071010213101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)