Provider Demographics
NPI:1043968134
Name:PETRY, BRIAN (MA, MBA, LPCC, LMFT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PETRY
Suffix:
Gender:
Credentials:MA, MBA, LPCC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7083
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7083
Mailing Address - Country:US
Mailing Address - Phone:951-344-1444
Mailing Address - Fax:
Practice Address - Street 1:10275 HOLE AVE UNIT 7083
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92513-3404
Practice Address - Country:US
Practice Address - Phone:909-292-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18322101YP2500X
CA153174106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional