MEDICARE: ERIC VERNON PETTINGILL LCPC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1881791754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC VERNON PETTINGILL LCPC

Provider Business Mailing Address
First Line	:	PO BOX 18
Second Line	:
City	:	SAINT ANTHONY
State	:	ID
Zip	:	83445-0018
Country	:	US
Telephone Number	:	208-356-4900
Fax Number	:	208-624-4030

Provider Business Practice Location Address
First Line	:	3729 WOODKING DR STE 1
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4720
Country	:	US
Telephone Number	:	208-356-4900
Fax Number	:	208-612-6118

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	09/05/2024

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