Provider Demographics
NPI:1477964690
Name:PETTY, ALLEN RICHARD I (LMSW,CAC)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:RICHARD
Last Name:PETTY
Suffix:I
Gender:M
Credentials:LMSW,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-9780
Mailing Address - Country:US
Mailing Address - Phone:517-525-6544
Mailing Address - Fax:
Practice Address - Street 1:181 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-9780
Practice Address - Country:US
Practice Address - Phone:517-525-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801070044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health