Provider Demographics
NPI:1508628033
Name:PETTIS, ACQUANITA (LCSW, LISW-CP)
Entity Type:Individual
Prefix:
First Name:ACQUANITA
Middle Name:
Last Name:PETTIS
Suffix:
Gender:F
Credentials:LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 BROOKSTONE WAY APT 304
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2688
Mailing Address - Country:US
Mailing Address - Phone:561-503-8230
Mailing Address - Fax:
Practice Address - Street 1:1961 BROOKSTONE WAY APT 304
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2688
Practice Address - Country:US
Practice Address - Phone:561-503-8230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16505103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical