Provider Demographics
NPI:1336277508
Name:PETTEWAY, LINDA DIANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:DIANNE
Last Name:PETTEWAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 ALLSTATE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1702
Mailing Address - Country:US
Mailing Address - Phone:213-369-0162
Mailing Address - Fax:
Practice Address - Street 1:4590 ALLSTATE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1702
Practice Address - Country:US
Practice Address - Phone:213-369-0162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA49813106H00000X
CAMFC 49813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist