Provider Demographics
NPI:1124533757
Name:PETTINGA, MATTHEW SCOTT (MA, LPC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:PETTINGA
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5557 28TH ST SE STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2035
Mailing Address - Country:US
Mailing Address - Phone:616-303-4599
Mailing Address - Fax:
Practice Address - Street 1:5557 28TH ST SE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2035
Practice Address - Country:US
Practice Address - Phone:616-303-4599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015324101Y00000X
MI6301016588103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty