Provider Demographics
NPI:1598030801
Name:PETTY, MICHELLE L (MS, LCPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:PETTY
Suffix:
Gender:F
Credentials:MS, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11447 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9522
Mailing Address - Country:US
Mailing Address - Phone:815-979-1085
Mailing Address - Fax:
Practice Address - Street 1:11447 2ND ST
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9522
Practice Address - Country:US
Practice Address - Phone:815-979-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007926101YP2500X
IL180.009475101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional