Provider Demographics
NPI:1366711939
Name:PETTIFORD, TINA YVONNE (LPC)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:YVONNE
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:YVONNE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3805 ROBIN DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2268
Mailing Address - Country:US
Mailing Address - Phone:618-244-5119
Mailing Address - Fax:
Practice Address - Street 1:5501 N PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62204-2121
Practice Address - Country:US
Practice Address - Phone:618-244-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.006219101Y00000X, 101YM0800X, 101YP2500X, 106H00000X
IL2341716101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist