Provider Demographics
NPI:1790989119
Name:PETTY-HANNUM, ALICE D (MFT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:D
Last Name:PETTY-HANNUM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:D
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:406 CHINN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4339
Mailing Address - Country:US
Mailing Address - Phone:707-495-5350
Mailing Address - Fax:707-570-2680
Practice Address - Street 1:406 CHINN ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4339
Practice Address - Country:US
Practice Address - Phone:707-495-5350
Practice Address - Fax:707-570-2680
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43967106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist