Provider Demographics
NPI:1700235884
Name:PETTY, JOSEPH JR
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PETTY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3105
Mailing Address - Country:US
Mailing Address - Phone:310-831-0331
Mailing Address - Fax:310-831-0004
Practice Address - Street 1:599 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3105
Practice Address - Country:US
Practice Address - Phone:310-831-0331
Practice Address - Fax:310-831-0004
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)