Provider Demographics
NPI:1962878694
Name:PETTAWAY, ASHLEY (MS)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:
Last Name:PETTAWAY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6817
Mailing Address - Country:US
Mailing Address - Phone:407-448-6678
Mailing Address - Fax:
Practice Address - Street 1:1050 REGAL POINTE TER
Practice Address - Street 2:APT 206
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2028
Practice Address - Country:US
Practice Address - Phone:267-980-4556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health