Provider Demographics
NPI:1730673633
Name:PETTY, RICHARD JOSHUA
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSHUA
Last Name:PETTY
Suffix:
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 1:211 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:DUBACH
Mailing Address - State:LA
Mailing Address - Zip Code:71235-3346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 BROWN RD
Practice Address - Street 2:
Practice Address - City:DUBACH
Practice Address - State:LA
Practice Address - Zip Code:71235-3346
Practice Address - Country:US
Practice Address - Phone:318-257-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer