Basic Information
| Provider Information | |||||||||
| NPI: | 1215388814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIWAY | ||||||||
| FirstName: | DERRELL | ||||||||
| MiddleName: | RASHAD | ||||||||
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| Credential: | MSW, LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 YONKERS RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276042258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194930959 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2515 E NC HIGHWAY 54 BLDG 2200 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277135251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194930959 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2016 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P010476 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X | 1199035 | NC | N | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.