Healthcare Provider Details

I. General information

NPI: 1417677600
Provider Name (Legal Business Name): MARNIE MICHELLE PETTIT LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DISTRICT AVE
BURLINGTON MA
01803-5069
US

IV. Provider business mailing address

1500 DISTRICT AVE
BURLINGTON MA
01803-5069
US

V. Phone/Fax

Practice location:
  • Phone: 469-630-2916
  • Fax:
Mailing address:
  • Phone: 469-630-2916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10000801
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number100.0134548TELE
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number204678
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: