Provider Demographics
NPI:1104036821
Name:PETTIS, MICHAEL H (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:H
Last Name:PETTIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4600
Mailing Address - Country:US
Mailing Address - Phone:662-842-4651
Mailing Address - Fax:662-842-7335
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE D-1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-842-4651
Practice Address - Fax:662-842-7335
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC79711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical