Provider Demographics
NPI:1043312374
Name:PELLERIN, ROBERT M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:PELLERIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:M
Other - Last Name:PELLERIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:1110 MELODY LN
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5193
Mailing Address - Country:US
Mailing Address - Phone:916-878-7657
Mailing Address - Fax:916-771-4404
Practice Address - Street 1:1110 MELODY LN
Practice Address - Street 2:SUITE 125
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5193
Practice Address - Country:US
Practice Address - Phone:916-878-7657
Practice Address - Fax:916-771-4404
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 44461251S00000X
CAMFC 48241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No251S00000XAgenciesCommunity/Behavioral Health