Provider Demographics
NPI:1821434622
Name:PETTRY, ARCHIE MAURICE III (MS)
Entity Type:Individual
Prefix:
First Name:ARCHIE
Middle Name:MAURICE
Last Name:PETTRY
Suffix:III
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S WOLCOTT ST STE 301
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2690
Mailing Address - Country:US
Mailing Address - Phone:307-466-8008
Mailing Address - Fax:
Practice Address - Street 1:136 S WOLCOTT ST STE 301
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2690
Practice Address - Country:US
Practice Address - Phone:307-466-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1522101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health