Provider Demographics
NPI:1043075765
Name:PETTIFORD, LERLA (LPC-A)
Entity type:Individual
Prefix:
First Name:LERLA
Middle Name:
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 RANCH ROAD 1869
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-4101
Mailing Address - Country:US
Mailing Address - Phone:737-234-5080
Mailing Address - Fax:
Practice Address - Street 1:201 SAINT JOSEPH CT
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-3403
Practice Address - Country:US
Practice Address - Phone:703-774-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health