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General NPI Number Information
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NPI Number | 1104036821
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Entity Type | Individual
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Provider Name | MICHAEL H PETTIS LCSW
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Gender | Male
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 499 GLOSTER CREEK VLG SUITE D-1
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City | TUPELO
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State | MS
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Zip | 38801-4600
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Country | US
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Telephone | 662-842-4651
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Fax | 662-842-7335
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Provider Business Mailing Address
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Address Line | 499 GLOSTER CREEK VLG SUITE D-1
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City | TUPELO
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State | MS
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Zip | 38801-4600
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Country | US
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Telephone | 662-842-4651
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Fax | 662-842-7335
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C7971
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License Number State | MS
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