Provider Demographics
NPI:1093063810
Name:PETTIFORD, TONYA (MA)
Entity Type:Individual
Prefix:MS
First Name:TONYA
Middle Name:
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 771506
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34477-1506
Mailing Address - Country:US
Mailing Address - Phone:678-994-4466
Mailing Address - Fax:
Practice Address - Street 1:1329 SW 16TH ST
Practice Address - Street 2:SUITE 4160
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1128
Practice Address - Country:US
Practice Address - Phone:352-273-8563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051053490104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker