Individual
MR. KEVIN LEE PETTUS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CCS, ACADC
Contact information
Practice address
25431 HWY 93, CHALLIS, IDAHO 83226, ID 83226-8322
(208) 879-2267
Mailing address
397 RIVER DR, CHALLIS, ID 83226-4840
(280) 833-7632
(208) 879-2089
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
12002
ID
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
13012
ID
Other
Enumeration date
07/05/2014
Last updated
09/03/2021
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