Provider Demographics
NPI:1528361037
Name:PETTY, JANET LEE (MA, LPC, CCDP-D)
Entity Type:Individual
Prefix:MRS
First Name:JANET
Middle Name:LEE
Last Name:PETTY
Suffix:
Gender:F
Credentials:MA, LPC, CCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N GRAND ST
Mailing Address - Street 2:P.O. BOX 429
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-1344
Mailing Address - Country:US
Mailing Address - Phone:573-729-4103
Mailing Address - Fax:573-729-4420
Practice Address - Street 1:203 N GRAND ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-1344
Practice Address - Country:US
Practice Address - Phone:573-729-4103
Practice Address - Fax:573-729-4420
Is Sole Proprietor?:No
Enumeration Date:2010-12-06
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3770101YA0400X
MO2008037617101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008037617OtherDIVISON OF PROFESSIONAL REGISTRATION, COMMITTEE FOR PROFESSIONAL COUNSELORS