Provider Demographics
NPI:1770365827
Name:PETTINGILL COUNSELING PC
Entity type:Organization
Organization Name:PETTINGILL COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTINGILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-227-4600
Mailing Address - Street 1:1302 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6270
Mailing Address - Country:US
Mailing Address - Phone:208-542-9919
Mailing Address - Fax:208-542-6272
Practice Address - Street 1:1302 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6270
Practice Address - Country:US
Practice Address - Phone:208-542-9919
Practice Address - Fax:208-542-6272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty