Provider Demographics
NPI:1992957526
Name:PETTY, ANNE L (LCSW)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:L
Last Name:PETTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 BUCHANAN ST
Mailing Address - Street 2:#204
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2959
Mailing Address - Country:US
Mailing Address - Phone:707-746-7477
Mailing Address - Fax:
Practice Address - Street 1:735 BUCHANAN ST
Practice Address - Street 2:#204
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2959
Practice Address - Country:US
Practice Address - Phone:707-746-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 38211041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator