Provider Demographics
NPI:1902915705
Name:PETTIGREW, DOROTHY CAROL (PSY D)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:CAROL
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:PSY D
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 310035
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77231-0035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2626 SOUTH LOOP W
Practice Address - Street 2:SUITE 406
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2654
Practice Address - Country:US
Practice Address - Phone:713-218-6855
Practice Address - Fax:713-218-6983
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22570103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00SD93Medicare ID - Type Unspecified