Provider Demographics
NPI:1265848717
Name:PETTUS, KEVIN LEE (CCS, ACADC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:PETTUS
Suffix:
Gender:M
Credentials:CCS, ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226-4840
Mailing Address - Country:US
Mailing Address - Phone:280-833-7632
Mailing Address - Fax:208-879-2089
Practice Address - Street 1:25431 HWY 93
Practice Address - Street 2:
Practice Address - City:CHALLIS, IDAHO 83226
Practice Address - State:ID
Practice Address - Zip Code:83226-8322
Practice Address - Country:US
Practice Address - Phone:208-879-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-05
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12002101YA0400X
ID13012101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)