Provider Demographics
NPI:1578764981
Name:PETTIFORD, LORETTA CLARISE (MSW,LICSW,LCSW-C,CP)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:CLARISE
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MSW,LICSW,LCSW-C,CP
Other - Prefix:MRS
Other - First Name:LORETTA
Other - Middle Name:CLARISE
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12611 HENRY DR SW
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6147
Mailing Address - Country:US
Mailing Address - Phone:240-727-2451
Mailing Address - Fax:301-777-1951
Practice Address - Street 1:12611 HENRY DR SW
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-6147
Practice Address - Country:US
Practice Address - Phone:240-727-2451
Practice Address - Fax:301-777-1951
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13717104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4172248 00Medicaid