Provider Demographics
NPI:1578359758
Name:PETRY, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PETRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENT
Mailing Address - State:MN
Mailing Address - Zip Code:55947-1010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5467
Practice Address - Country:US
Practice Address - Phone:608-775-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral