Provider Demographics
NPI:1659782647
Name:PETTY, TRISTAN K (LPC/MHSP)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:K
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPC/MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W DUE WEST AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-4420
Mailing Address - Country:US
Mailing Address - Phone:615-964-7113
Mailing Address - Fax:615-928-8482
Practice Address - Street 1:607 W DUE WEST AVE STE 106
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4420
Practice Address - Country:US
Practice Address - Phone:615-964-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional