Provider Demographics
NPI:1639678667
Name:PETTITT, CONSTANCE (LPC, LAC)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:PETTITT
Suffix:
Gender:F
Credentials:LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 DALE ST STE B
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-1794
Mailing Address - Country:US
Mailing Address - Phone:719-344-3864
Mailing Address - Fax:
Practice Address - Street 1:709 DALE ST STE B
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1794
Practice Address - Country:US
Practice Address - Phone:719-344-3864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90000158233Medicaid