Provider Demographics
NPI:1215388814
Name:PETTIWAY, DERRELL RASHAD (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:DERRELL
Middle Name:RASHAD
Last Name:PETTIWAY
Suffix:
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 YONKERS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2258
Mailing Address - Country:US
Mailing Address - Phone:919-493-0959
Mailing Address - Fax:
Practice Address - Street 1:2515 E NC HIGHWAY 54 BLDG 2200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5251
Practice Address - Country:US
Practice Address - Phone:919-493-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0104761041C0700X
NC11990351041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool