1578764981 NPI number — MRS. LORETTA CLARISE PETTIFORD MSW,LICSW,LCSW-C,C.P

Table of content: MRS. LORETTA CLARISE PETTIFORD MSW,LICSW,LCSW-C,C.P (NPI 1578764981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578764981 NPI number — MRS. LORETTA CLARISE PETTIFORD MSW,LICSW,LCSW-C,C.P

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTIFORD
Provider First Name:
LORETTA
Provider Middle Name:
CLARISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW,LICSW,LCSW-C,C.P
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANE
Provider Other First Name:
LORETTA
Provider Other Middle Name:
CLARISE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578764981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12611 HENRY DR SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAVALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21502-6147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-727-2451
Provider Business Mailing Address Fax Number:
301-777-1951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12611 HENRY DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-6147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-727-2451
Provider Business Practice Location Address Fax Number:
301-777-1951
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  13717 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4172248 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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