Provider Demographics
NPI:1417746447
Name:PETTY, CAROLINE (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:PETTY
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2966 TABERNACLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-9622
Mailing Address - Country:US
Mailing Address - Phone:662-352-6562
Mailing Address - Fax:
Practice Address - Street 1:2966 TABERNACLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-9622
Practice Address - Country:US
Practice Address - Phone:662-352-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC106091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical