Provider Demographics
NPI:1083047567
Name:PETTIT, SHANTEL NICHOLE (CSW)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:NICHOLE
Last Name:PETTIT
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 W MARKET CENTER DR
Mailing Address - Street 2:#1200
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-8026
Mailing Address - Country:US
Mailing Address - Phone:801-240-9436
Mailing Address - Fax:
Practice Address - Street 1:3740 W MARKET CENTER DR
Practice Address - Street 2:#1200
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-8026
Practice Address - Country:US
Practice Address - Phone:801-240-9436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5987144-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical