MEDICARE: MRS. TINA YVONNE PETTIFORD LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	178.006219	IL
2	101YM0800X	Mental Health Counselor	178.006219	IL
3	101YP2500X	Professional Counselor	178.006219	IL
4	101YS0200X	School Counselor	2341716	IL
5	106H00000X	Marriage & Family Therapist	178.006219	IL

General Provider Information

NPI Number	:	1366711939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TINA YVONNE PETTIFORD LPC

Provider Business Mailing Address
First Line	:	3805 ROBIN DR
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-2268
Country	:	US
Telephone Number	:	618-244-5119
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 N PARK DR
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2121
Country	:	US
Telephone Number	:	618-244-5119
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2011
Last Update Date	:	12/27/2011

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