Healthcare Provider Details

I. General information

NPI: 1578976569
Provider Name (Legal Business Name): PAUL PELLETIER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 N CALIFORNIA ST STE B
STOCKTON CA
95204-6029
US

IV. Provider business mailing address

9703 NANTUCKET DR
STOCKTON CA
95209-1441
US

V. Phone/Fax

Practice location:
  • Phone: 209-463-0870
  • Fax: 209-463-1803
Mailing address:
  • Phone: 209-986-7010
  • Fax: 209-463-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: