MEDICARE: TYLER PETTIGREW

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	101Y00000X	Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1427583475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER PETTIGREW

Provider Business Mailing Address
First Line	:	2127 WILLOW ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70113-2923
Country	:	US
Telephone Number	:	504-405-0694
Fax Number	:

Provider Business Practice Location Address
First Line	:	2127 WILLOW ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70113-2923
Country	:	US
Telephone Number	:	504-405-0694
Fax Number	:

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

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/07/2022

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Directions to “ TYLER PETTIGREW ” Practice Location

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