Provider Demographics
NPI:1548611528
Name:PETTWAY, BARBARA ANNE
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:ANNE
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BARBARA
Other - Middle Name:ANNE
Other - Last Name:PETTWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1413 FIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2321
Mailing Address - Country:US
Mailing Address - Phone:313-347-2070
Mailing Address - Fax:313-579-1819
Practice Address - Street 1:1413 FIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2321
Practice Address - Country:US
Practice Address - Phone:313-347-2070
Practice Address - Fax:313-579-1819
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251B00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-15555827Medicaid