Provider Demographics
NPI:1821119801
Name:PETTUS, SALLY L (SALLY PETTUS EDD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:L
Last Name:PETTUS
Suffix:
Gender:F
Credentials:SALLY PETTUS EDD
Other - Prefix:MS
Other - First Name:SALLY
Other - Middle Name:F
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:241 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-5106
Mailing Address - Country:US
Mailing Address - Phone:508-636-6854
Mailing Address - Fax:
Practice Address - Street 1:400 FAUNCE CORNER RD
Practice Address - Street 2:SHERIFF'S OFFICE
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1275
Practice Address - Country:US
Practice Address - Phone:508-995-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical