Provider Demographics
NPI:1336731645
Name:PETTICORD, CAITYANNE LEIGH
Entity type:Individual
Prefix:
First Name:CAITYANNE
Middle Name:LEIGH
Last Name:PETTICORD
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 1:1389 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2101
Mailing Address - Country:US
Mailing Address - Phone:317-564-0934
Mailing Address - Fax:
Practice Address - Street 1:1389 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2101
Practice Address - Country:US
Practice Address - Phone:317-564-0934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician