Provider Demographics
NPI:1780119602
Name:PETTY, TARANESHA (LCSW)
Entity type:Individual
Prefix:
First Name:TARANESHA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17022 BLUE MIST CIR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-4814
Mailing Address - Country:US
Mailing Address - Phone:318-751-3656
Mailing Address - Fax:
Practice Address - Street 1:17022 BLUE MIST CIRCLE
Practice Address - Street 2:
Practice Address - City:SUGARLAND
Practice Address - State:TX
Practice Address - Zip Code:77498
Practice Address - Country:US
Practice Address - Phone:318-751-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62963101YP2500X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker