1568055234 NPI number — MRS. KRISTEN MARIE PETTINATO LPC

Table of content: MRS. KRISTEN MARIE PETTINATO LPC (NPI 1568055234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568055234 NPI number — MRS. KRISTEN MARIE PETTINATO LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTINATO
Provider First Name:
KRISTEN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568055234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 DOGWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19426-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-608-9508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 OLD SWEDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19518-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-910-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  PC012874 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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