Provider Demographics
NPI:1356366504
Name:PETTY, GARY LEON (PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LEON
Last Name:PETTY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 BISSONNET ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-1711
Mailing Address - Country:US
Mailing Address - Phone:281-447-0847
Mailing Address - Fax:713-589-9631
Practice Address - Street 1:1118 BARKDULL ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-6402
Practice Address - Country:US
Practice Address - Phone:281-447-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034754401Medicaid
TX034754401Medicaid