Provider Demographics
NPI:1750071494
Name:PETTAWAY, TRINAE'
Entity type:Individual
Prefix:
First Name:TRINAE'
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 CONKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-5100
Mailing Address - Country:US
Mailing Address - Phone:504-908-6802
Mailing Address - Fax:
Practice Address - Street 1:1072 CONKLIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77088-5100
Practice Address - Country:US
Practice Address - Phone:504-908-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator