Provider Demographics
NPI:1629081864
Name:PETTINGILL, TAMARA K (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:K
Last Name:PETTINGILL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6270
Mailing Address - Country:US
Mailing Address - Phone:208-542-9199
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:208-542-9199
Practice Address - Fax:208-542-6272
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IDLCSW-24477101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806864000Medicaid
ID806836700Medicaid
ID806803500Medicaid