Provider Demographics
NPI:1104150705
Name:PETTITT, STACY LYNN (MSW)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:PETTITT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 NE MAPLE
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163
Mailing Address - Country:US
Mailing Address - Phone:509-334-1133
Mailing Address - Fax:509-332-1608
Practice Address - Street 1:340 NE MAPLE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-334-1133
Practice Address - Fax:509-334-1133
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA60567471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker