Provider Demographics
NPI:1528480084
Name:PETTEWAY, CHRISTINE ELIZABETH (AUD, CCC-A)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:PETTEWAY
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ELIZABETH
Other - Last Name:LUKIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:300 W LINCOLN ST
Mailing Address - Street 2:102
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1987
Mailing Address - Country:US
Mailing Address - Phone:618-234-9705
Mailing Address - Fax:
Practice Address - Street 1:300 W LINCOLN ST
Practice Address - Street 2:102
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1987
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013039522231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist