Provider Demographics
NPI:1679218606
Name:PETTY, MARIAN (HOLISTIC)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:HOLISTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 W FORT WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-2301
Mailing Address - Country:US
Mailing Address - Phone:256-487-6072
Mailing Address - Fax:309-863-5828
Practice Address - Street 1:1023 W FORT WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2301
Practice Address - Country:US
Practice Address - Phone:256-487-6072
Practice Address - Fax:309-863-5828
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251G00000X, 261QH0100X, 374K00000X, 174400000X, 2251H1200X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand