Provider Demographics
NPI:1346674751
Name:PETTIT, KENDRA TAMAR (LPC)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:TAMAR
Last Name:PETTIT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 MACE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5710
Mailing Address - Country:US
Mailing Address - Phone:208-991-0076
Mailing Address - Fax:
Practice Address - Street 1:1108 W FINCH DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1732
Practice Address - Country:US
Practice Address - Phone:208-991-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional