Provider Demographics
NPI:1851749162
Name:PETTWAY, NICHOLE DIANE (NCAC1 CATS 1)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DIANE
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:NCAC1 CATS 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 MONACO DR
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-4151
Mailing Address - Country:US
Mailing Address - Phone:650-771-1908
Mailing Address - Fax:415-703-0550
Practice Address - Street 1:839 MONACO DR
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-4151
Practice Address - Country:US
Practice Address - Phone:650-771-1908
Practice Address - Fax:415-703-0550
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA015838101YA0400X
CA143628I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)