Provider Demographics
NPI:1295596260
Name:PETTY, HEATHER (CSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7159
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40257-0159
Mailing Address - Country:US
Mailing Address - Phone:855-591-0092
Mailing Address - Fax:
Practice Address - Street 1:200 SEMINOLE TRL
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1115
Practice Address - Country:US
Practice Address - Phone:859-213-9646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY254933101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health