Provider Demographics
NPI:1427318369
Name:PETTY, GRACE E (MA LPC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:PETTY
Suffix:
Gender:F
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 COURT ST
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1312
Mailing Address - Country:US
Mailing Address - Phone:434-455-1000
Mailing Address - Fax:434-485-8877
Practice Address - Street 1:3410 OLD FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2915
Practice Address - Country:US
Practice Address - Phone:434-455-1000
Practice Address - Fax:434-485-8877
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64798101YM0800X
VA0701005872101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health