Provider Demographics
NPI:1588269989
Name:PETTWAY, COLEMAN JR
Entity type:Individual
Prefix:MR
First Name:COLEMAN
Middle Name:
Last Name:PETTWAY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 641
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-0641
Mailing Address - Country:US
Mailing Address - Phone:516-592-8452
Mailing Address - Fax:
Practice Address - Street 1:89 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1517
Practice Address - Country:US
Practice Address - Phone:516-592-8452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker