Provider Demographics
NPI:1942964283
Name:PETTINICHIO, CHRIS
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:PETTINICHIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-1553
Mailing Address - Country:US
Mailing Address - Phone:209-206-0842
Mailing Address - Fax:
Practice Address - Street 1:564 MOUNTAIN RANCH RD STE 5
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9782
Practice Address - Country:US
Practice Address - Phone:530-626-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool