Provider Demographics
NPI:1477994937
Name:PETTY, WILLIAM C
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W SWANSON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6853
Mailing Address - Country:US
Mailing Address - Phone:907-376-5228
Mailing Address - Fax:907-376-8126
Practice Address - Street 1:351 W SWANSON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6853
Practice Address - Country:US
Practice Address - Phone:907-376-5228
Practice Address - Fax:907-376-8126
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK493101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor