Healthcare Provider Details

I. General information

NPI: 1215388814
Provider Name (Legal Business Name): DERRELL RASHAD PETTIWAY MSW, LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 E NC HIGHWAY 54 BLDG 2200
DURHAM NC
27713-5251
US

IV. Provider business mailing address

2000 YONKERS RD
RALEIGH NC
27604-2258
US

V. Phone/Fax

Practice location:
  • Phone: 919-493-0959
  • Fax:
Mailing address:
  • Phone: 919-493-0959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP010476
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1199035
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: