Provider Demographics
NPI:1245541705
Name:PETTY, JOHN DAVID (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:PETTY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 EARLS WAY
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05346-8617
Mailing Address - Country:US
Mailing Address - Phone:802-258-1222
Mailing Address - Fax:802-387-2211
Practice Address - Street 1:68 EARLS WAY
Practice Address - Street 2:
Practice Address - City:PUTNEY
Practice Address - State:VT
Practice Address - Zip Code:05346-8617
Practice Address - Country:US
Practice Address - Phone:802-387-5011
Practice Address - Fax:802-387-2299
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0110630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical