Provider Demographics
NPI:1134735665
Name:PETTY, ADRIENNE ROMAYNE (LPC)
Entity type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:ROMAYNE
Last Name:PETTY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4883 BRISTOL ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7104
Mailing Address - Country:US
Mailing Address - Phone:314-441-6679
Mailing Address - Fax:
Practice Address - Street 1:12100 OLD HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BLACK JACK
Practice Address - State:MO
Practice Address - Zip Code:63033-7112
Practice Address - Country:US
Practice Address - Phone:314-441-6679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017043874101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty