Basic Information
Provider Information | |||||||||
NPI: | 1316924350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETTY | ||||||||
FirstName: | TERRI | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 125 WELLNESS WAY | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016247111 | ||||||||
FaxNumber: | 5016205109 | ||||||||
Practice Location | |||||||||
Address1: | 125 WELLNESS WAY | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 71913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016247111 | ||||||||
FaxNumber: | 5016205109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2005 | ||||||||
LastUpdateDate: | 07/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P9807015 | AR | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 116399726 | 05 | AR |   | MEDICAID | 222090 | 01 | AR | UNITED BEHAVIORAL HEALTH | OTHER | 5X327 | 01 | AR | BLUE CROSS/BLUE SHIELD | OTHER | 2159301 | 01 | AR | CIGNA BEHAVIORAL HEALTH | OTHER | 3070018000 | 01 | AR | QUAL-CHOICE | OTHER | 3509001000 | 01 | AR | MAGELLAN | OTHER | 216631 | 01 | AR | MHN NETWORK | OTHER | 60054 | 01 | AR | AETNA | OTHER | 71-0401764 | 01 | AR | CORPHEALTH | OTHER | 562340 | 01 | AR | VALUE OPTIONS | OTHER |