| Doctor Name: | MR. KEVIN LEE PETTUS |
| NPI Number: | 1265848717 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CADC |
| License Number: | 10197 |
| Business Practice Address: | 605 11th Ave E Gooding, ID - 833305368 |
| Business Phone Number: | 2089348461 |
| Business Fax Number: | |
| Mailing Address: | 1254 Twin Villa Loop, TWIN FALLS |
| State: | ID |
| Postal Code: | 833018018 |
| Phone Number: | 2083202518 |
| Fax Number: | |
| NPI Enumeration Date: | 07/05/2014 |
| NPI Last Update Date: | 07/05/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 10197 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |