Provider Demographics
NPI:1649474156
Name:PETTIT, SHANNON E (LCSW, CADC, CCS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:PETTIT
Suffix:
Gender:F
Credentials:LCSW, CADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PENOBSCOT AVE
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1320
Mailing Address - Country:US
Mailing Address - Phone:207-949-3270
Mailing Address - Fax:
Practice Address - Street 1:68 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4096
Practice Address - Country:US
Practice Address - Phone:207-949-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC4201101YA0400X
MECCS8417101YA0400X
MELC130001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)