Provider Demographics
NPI:1457916660
Name:PETTENGILL, AMY (MLADC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PETTENGILL
Suffix:
Gender:F
Credentials:MLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LAKE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-2734
Mailing Address - Country:US
Mailing Address - Phone:603-622-3020
Mailing Address - Fax:603-622-8094
Practice Address - Street 1:700 LAKE AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2734
Practice Address - Country:US
Practice Address - Phone:603-622-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0957101YA0400X
NH1233101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3126041Medicaid