Healthcare Provider Details

I. General information

NPI: 1770970063
Provider Name (Legal Business Name): JOY PETWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 400
LARGO MD
20774-4791
US

IV. Provider business mailing address

5202 56TH AVE
HYATTSVILLE MD
20781-2903
US

V. Phone/Fax

Practice location:
  • Phone: 301-772-0105
  • Fax: 301-772-0103
Mailing address:
  • Phone: 757-719-1926
  • Fax: 301-779-1789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17236
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079818
License Number StateDC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: