Provider Demographics
NPI:1215106588
Name:PELLETIER, JOHN R
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 ADAMSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-5001
Mailing Address - Country:US
Mailing Address - Phone:508-636-7227
Mailing Address - Fax:
Practice Address - Street 1:83 ADAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-5001
Practice Address - Country:US
Practice Address - Phone:508-636-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3373103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist