Provider Demographics
NPI:1629878442
Name:PETTAWAY, MARQUES TYRELL
Entity type:Individual
Prefix:
First Name:MARQUES
Middle Name:TYRELL
Last Name:PETTAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 KENDALL DR APT 5013
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-4162
Mailing Address - Country:US
Mailing Address - Phone:909-695-9708
Mailing Address - Fax:
Practice Address - Street 1:8287 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-466-4001
Practice Address - Fax:888-311-5333
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician