Provider Demographics
NPI:1447145453
Name:PETTY, SHAUNDA RENA
Entity type:Individual
Prefix:
First Name:SHAUNDA
Middle Name:RENA
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 W FRONT ST STE 262
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-7975
Mailing Address - Country:US
Mailing Address - Phone:903-636-3868
Mailing Address - Fax:
Practice Address - Street 1:719 W FRONT ST STE 262
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7975
Practice Address - Country:US
Practice Address - Phone:903-636-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96260101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health