Healthcare Provider Details

I. General information

NPI: 1114847175
Provider Name (Legal Business Name): TAMARA FIELDS PETTIT MS, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E GRANADA BLVD STE 103
ORMOND BEACH FL
32176-6660
US

IV. Provider business mailing address

100 E GRANADA BLVD STE 103
ORMOND BEACH FL
32176-6660
US

V. Phone/Fax

Practice location:
  • Phone: 386-999-1989
  • Fax:
Mailing address:
  • Phone: 386-999-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMT5534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: