Provider Demographics
NPI:1649453507
Name:PETTY, DOROTHY S (LMSW)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:S
Last Name:PETTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:DOROTHY
Other - Middle Name:S
Other - Last Name:HUTCHINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:17 W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3826
Mailing Address - Country:US
Mailing Address - Phone:516-868-3030
Mailing Address - Fax:
Practice Address - Street 1:17 W MERRICK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3826
Practice Address - Country:US
Practice Address - Phone:516-868-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077933-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01666971Medicaid