Provider Demographics
NPI:1417723768
Name:PETTY, TEQUILA BREYONDA (OT)
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:BREYONDA
Last Name:PETTY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-0749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 2ND ST NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-6105
Practice Address - Country:US
Practice Address - Phone:828-358-0976
Practice Address - Fax:828-838-1057
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16408225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist