Provider Demographics
NPI:1578058608
Name:PETTIS, SHARDE BRYAUN (MA)
Entity Type:Individual
Prefix:MS
First Name:SHARDE
Middle Name:BRYAUN
Last Name:PETTIS
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 1:2825 BURNET AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2426
Mailing Address - Country:US
Mailing Address - Phone:513-558-5857
Mailing Address - Fax:
Practice Address - Street 1:2825 BURNET AVE FL 4
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2426
Practice Address - Country:US
Practice Address - Phone:513-558-5857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2020-04-29
Deactivation Date:2020-04-02
Deactivation Code:
Reactivation Date:2020-04-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent