Provider Demographics
NPI:1104108323
Name:PETRY, JOHN D (LPCC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:PETRY
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 HILTON DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1752
Mailing Address - Country:US
Mailing Address - Phone:937-479-4828
Mailing Address - Fax:
Practice Address - Street 1:474 N YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2463
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1000175101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional