Provider Demographics
NPI:1730751306
Name:PELLETIER, NICHOLAS JOSEPH
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
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 1:1469 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-1045
Mailing Address - Country:US
Mailing Address - Phone:978-228-8023
Mailing Address - Fax:
Practice Address - Street 1:33 UTICA DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1622
Practice Address - Country:US
Practice Address - Phone:978-228-8023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-23-66387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst