Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | LMSW-13458 | AZ |
N | 1041C0700X | Clinical Social Worker | 071208 | NY |
NPI | 1003241803 |
---|---|
Provider Name | Mr. Randall Berwin Pettit |
First Address | Tucson, AZ 85704-7736 |
Second Address | Tucson, AZ 85704-7736 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2013 |
Last Update Date | 11/09/2013 |