Provider Demographics
NPI:1295347094
Name:PETTY, ERIN BASS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:BASS
Last Name:PETTY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3401
Mailing Address - Country:US
Mailing Address - Phone:720-621-7512
Mailing Address - Fax:
Practice Address - Street 1:1123 8TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3401
Practice Address - Country:US
Practice Address - Phone:720-621-7512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13049235Z00000X
WVSP-2072235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty