Provider Demographics
NPI:1831564475
Name:PETTIT, LAURA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:PETTIT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 DUPONT CIR STE 228
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4825
Mailing Address - Country:US
Mailing Address - Phone:502-802-8691
Mailing Address - Fax:502-384-0478
Practice Address - Street 1:4010 DUPONT CIR STE 228
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4825
Practice Address - Country:US
Practice Address - Phone:502-802-8691
Practice Address - Fax:502-384-0478
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100438560Medicaid