Provider Demographics
NPI:1508413311
Name:PETTY, KATHERINE HELEN (PHD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HELEN
Last Name:PETTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80502-0147
Mailing Address - Country:US
Mailing Address - Phone:720-204-8744
Mailing Address - Fax:
Practice Address - Street 1:3333 IRIS AVE STE 104
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1998
Practice Address - Country:US
Practice Address - Phone:720-204-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 101YM0800X
COPSY.0006156103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health