Provider Demographics
NPI:1740489301
Name:PETTEWAY, DEJUANA LACHELLE DANZELL (LCSW, ASCW, ACHP-SW)
Entity type:Individual
Prefix:MRS
First Name:DEJUANA
Middle Name:LACHELLE DANZELL
Last Name:PETTEWAY
Suffix:
Gender:F
Credentials:LCSW, ASCW, ACHP-SW
Other - Prefix:
Other - First Name:DEJUANA
Other - Middle Name:LACHELLE
Other - Last Name:DANZELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 E STONER AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4243
Mailing Address - Country:US
Mailing Address - Phone:318-990-5781
Mailing Address - Fax:
Practice Address - Street 1:510 E. STONER AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4295
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA99001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical