Provider Demographics
NPI:1639307077
Name:PETTENGILL, MICHELLE MARGARET (BA, CADC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARGARET
Last Name:PETTENGILL
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1813
Mailing Address - Country:US
Mailing Address - Phone:641-856-6471
Mailing Address - Fax:641-856-2779
Practice Address - Street 1:221 E STATE ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1813
Practice Address - Country:US
Practice Address - Phone:641-856-6471
Practice Address - Fax:641-856-2779
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA09066OtherCADC