Provider Demographics
NPI:1508674763
Name:PETRY, CHANDLER M (ACMHC)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:M
Last Name:PETRY
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 E 800 S
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-5073
Mailing Address - Country:US
Mailing Address - Phone:303-656-3495
Mailing Address - Fax:
Practice Address - Street 1:321 N MALL DR.
Practice Address - Street 2:VW-103
Practice Address - City:ST.GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-767-1532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT96970066009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health