Provider Demographics
NPI:1073748323
Name:PETTIGREW, SHANTEL M
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:M
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3055
Mailing Address - Country:US
Mailing Address - Phone:217-373-2430
Mailing Address - Fax:
Practice Address - Street 1:801 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3055
Practice Address - Country:US
Practice Address - Phone:217-373-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health