Provider Demographics
NPI:1497934871
Name:LOCKHART-PETTAWAY, STEFANIE (PSYD, MSW)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:
Last Name:LOCKHART-PETTAWAY
Suffix:
Gender:F
Credentials:PSYD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9113 FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6565
Mailing Address - Country:US
Mailing Address - Phone:909-652-0361
Mailing Address - Fax:909-652-0241
Practice Address - Street 1:9113 FOOTHILL BLVD STE 130
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6565
Practice Address - Country:US
Practice Address - Phone:909-652-0361
Practice Address - Fax:909-652-0241
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24837103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist