Provider Demographics
NPI:1669833885
Name:PETITT, MEGAN ALLYSA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ALLYSA
Last Name:PETITT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 EMBARCADERO DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-3382
Mailing Address - Country:US
Mailing Address - Phone:209-956-4240
Mailing Address - Fax:
Practice Address - Street 1:6707 EMBARCADERO DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-3382
Practice Address - Country:US
Practice Address - Phone:209-956-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91956106H00000X
CALMFT112156106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF91956Medicaid