Provider Demographics
NPI:1053758417
Name:PETTY, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
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 1:801 NW WALLULA AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5455
Mailing Address - Country:US
Mailing Address - Phone:503-726-3800
Mailing Address - Fax:
Practice Address - Street 1:801 NW WALLULA AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5455
Practice Address - Country:US
Practice Address - Phone:503-726-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-25
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health