Provider Demographics
NPI:1396254652
Name:PETTY, BERNICE
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BERNICE
Other - Middle Name:
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDCA
Mailing Address - Street 1:1496 S GREEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4088
Mailing Address - Country:US
Mailing Address - Phone:162-389-7413
Mailing Address - Fax:162-916-0995
Practice Address - Street 1:1496 S GREEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4088
Practice Address - Country:US
Practice Address - Phone:162-389-7413
Practice Address - Fax:216-916-0995
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163462101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty