Provider Demographics
NPI:1699221358
Name:PETTINATO, MARK ANTHONY (LLPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:PETTINATO
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GLOCHESKI DR
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2639
Mailing Address - Country:US
Mailing Address - Phone:231-309-1781
Mailing Address - Fax:231-723-1735
Practice Address - Street 1:310 GLOCHESKI DR
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-2639
Practice Address - Country:US
Practice Address - Phone:231-309-1781
Practice Address - Fax:231-723-1735
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015039101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health