Provider Demographics
NPI:1003241803
Name:PETTIT, RANDALL BERWIN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:BERWIN
Last Name:PETTIT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 N ORACLE RD STE 505
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7736
Mailing Address - Country:US
Mailing Address - Phone:520-791-9974
Mailing Address - Fax:520-791-0676
Practice Address - Street 1:6700 N ORACLE RD STE 505
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7736
Practice Address - Country:US
Practice Address - Phone:520-791-9974
Practice Address - Fax:520-791-0676
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-13458104100000X
NY0712081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical