Provider Demographics
NPI:1750920369
Name:PETTWAY, SHANA NICOLE
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:NICOLE
Last Name:PETTWAY
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 1:66 SMITH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1218
Mailing Address - Country:US
Mailing Address - Phone:203-997-3610
Mailing Address - Fax:
Practice Address - Street 1:145 FITCH ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3706
Practice Address - Country:US
Practice Address - Phone:203-239-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician