Provider Demographics
NPI:1366802530
Name:PETTWAY, LELA
Entity type:Individual
Prefix:
First Name:LELA
Middle Name:
Last Name:PETTWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LELA
Other - Middle Name:MUAHADATUN
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:20 WOODLAWN CT
Mailing Address - Street 2:20 WOODLAWN COURT
Mailing Address - City:BLUE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:24064-1636
Mailing Address - Country:US
Mailing Address - Phone:540-314-0865
Mailing Address - Fax:111-111-1111
Practice Address - Street 1:20 WOODLAWN COURT
Practice Address - Street 2:20 WOODLAWN COURT
Practice Address - City:BLUE RIGDE
Practice Address - State:VA
Practice Address - Zip Code:24064
Practice Address - Country:US
Practice Address - Phone:540-314-0865
Practice Address - Fax:888-888-8888
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
VA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor