Provider Demographics
NPI:1790354421
Name:PETTY, CATHRINE (LSW)
Entity Type:Individual
Prefix:
First Name:CATHRINE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PERKINS LN
Mailing Address - Street 2:
Mailing Address - City:WEST CREEK
Mailing Address - State:NJ
Mailing Address - Zip Code:08092-9667
Mailing Address - Country:US
Mailing Address - Phone:609-661-3258
Mailing Address - Fax:
Practice Address - Street 1:122 LIEN ST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-6506
Practice Address - Country:US
Practice Address - Phone:732-233-2821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06306200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker