Provider Demographics
NPI:1538311865
Name:PETTINELLI, JAMES DOUGLAS
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DOUGLAS
Last Name:PETTINELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JAMES
Other - Middle Name:DOUGLAS
Other - Last Name:PETTINELLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:4500 W PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2186
Mailing Address - Country:US
Mailing Address - Phone:314-361-5983
Mailing Address - Fax:314-977-2614
Practice Address - Street 1:4500 W PINE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2186
Practice Address - Country:US
Practice Address - Phone:314-361-5983
Practice Address - Fax:314-977-2614
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0905103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily