Provider Demographics
NPI:1083937536
Name:PETTINELLI, MICHAEL A II (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:PETTINELLI
Suffix:II
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 HUNT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-1834
Mailing Address - Country:US
Mailing Address - Phone:315-335-4238
Mailing Address - Fax:
Practice Address - Street 1:6001 E MOLLOY RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13211-2100
Practice Address - Country:US
Practice Address - Phone:315-233-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077738-1104100000X
DEQ1-00010561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker