Provider Demographics
NPI:1013205053
Name:PELKEY, NICHOLAS JON (LADC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JON
Last Name:PELKEY
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:96 HARLOW ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4925
Mailing Address - Country:US
Mailing Address - Phone:207-945-9777
Mailing Address - Fax:207-945-9780
Practice Address - Street 1:96 HARLOW ST
Practice Address - Street 2:SUITE 360
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4925
Practice Address - Country:US
Practice Address - Phone:207-945-9777
Practice Address - Fax:207-945-9780
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5699101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)