Provider Demographics
NPI:1881791754
Name:PETTINGILL, ERIC VERNON (LCPC)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:VERNON
Last Name:PETTINGILL
Suffix:
Gender:M
Credentials:LCPC
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 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4030
Practice Address - Street 1:3729 WOODKING DR STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4720
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-612-6118
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional