Healthcare Provider Details

I. General information

NPI: 1538311865
Provider Name (Legal Business Name): DR. JAMES DOUGLAS PETTINELLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAMES DOUGLAS PETTINELLI PH.D.

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 10/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 W PINE BLVD
SAINT LOUIS MO
63108-2186
US

IV. Provider business mailing address

4500 W PINE BLVD
SAINT LOUIS MO
63108-2186
US

V. Phone/Fax

Practice location:
  • Phone: 314-361-5983
  • Fax: 314-977-2614
Mailing address:
  • Phone: 314-361-5983
  • Fax: 314-977-2614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number0905
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: