Provider Demographics
NPI:1316671274
Name:PETTAWAY, KIRSTEN MICHELE
Entity type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:MICHELE
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 1:2150 S POLLARD ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-5418
Mailing Address - Country:US
Mailing Address - Phone:703-851-6342
Mailing Address - Fax:
Practice Address - Street 1:2150 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-5418
Practice Address - Country:US
Practice Address - Phone:703-851-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health