Healthcare Provider Details

I. General information

NPI: 1881791754
Provider Name (Legal Business Name): ERIC VERNON PETTINGILL LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3729 WOODKING DR STE 1
IDAHO FALLS ID
83404-4720
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4900
  • Fax: 208-612-6118
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: