Provider Demographics
NPI:1811365034
Name:PETTIBONE, DONNA RENIE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:RENIE
Last Name:PETTIBONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:PETTIBONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, MS
Mailing Address - Street 1:1625 W OWEN K GARRIOTT RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5653
Mailing Address - Country:US
Mailing Address - Phone:580-242-4673
Mailing Address - Fax:580-242-4679
Practice Address - Street 1:1625 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5653
Practice Address - Country:US
Practice Address - Phone:580-242-4673
Practice Address - Fax:580-242-4679
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor