Basic Information
| Provider Information | |||||||||
| NPI: | 1629444583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTAWAY | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750A SOUTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514505095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13833 TAPIA AVE | ||||||||
| Address2: | |||||||||
| City: | BAYOU LA BATRE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365092515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514502211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3812C | AL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.