Basic Information
| Provider Information | |||||||||
| NPI: | 1992253744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRY | ||||||||
| FirstName: | FELICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 FEU FOLLET RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705084234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | 7136869413 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 DACOMA ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770928611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136869194 | ||||||||
| FaxNumber: | 7136869413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 73151 | TX | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 73151 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 362946101 | 05 | TX | MEDICAID |