Provider Demographics
NPI:1194847285
Name:PETTINGILL COUNSELING SERVICES, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PETTINGILL COUNSELING SERVICES, PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PETTINGILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-542-9919
Mailing Address - Street 1:2267 TETON PLZ
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6486
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:2007-04-06
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-24477101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806864000Medicaid