MEDICARE: TENISHA PETTUS MS, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MT4181	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376175026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TENISHA PETTUS MS, LMFT

Provider Business Mailing Address
First Line	:	9721 NW 3RD ST
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-6207
Country	:	US
Telephone Number	:	786-300-6778
Fax Number	:

Provider Business Practice Location Address
First Line	:	1533 SUNSET DR STE 225
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33143-5700
Country	:	US
Telephone Number	:	786-733-6422
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	12/21/2023

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