1518440486 NPI number — MRS. ANGELA DAWN CHEATHAM PETRY LPC

Table of content: MRS. ANGELA DAWN CHEATHAM PETRY LPC (NPI 1518440486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518440486 NPI number — MRS. ANGELA DAWN CHEATHAM PETRY LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRY
Provider First Name:
ANGELA
Provider Middle Name:
DAWN CHEATHAM
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518440486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9411 GUM FORK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLOTHIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23112-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-502-5622
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1909 HUGUENOT RD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CHESTERFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23235-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-350-7952
Provider Business Practice Location Address Fax Number:
866-330-1467
Provider Enumeration Date:
09/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0701007826 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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