Provider Demographics
NPI:1043636962
Name:PELLERIN, KYLIE (MS, LPES, NCSP)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:
Last Name:PELLERIN
Suffix:
Gender:F
Credentials:MS, LPES, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 PEARMAN DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-3801
Mailing Address - Country:US
Mailing Address - Phone:864-260-5135
Mailing Address - Fax:
Practice Address - Street 1:315 PEARMAN DAIRY RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-3801
Practice Address - Country:US
Practice Address - Phone:864-260-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4627103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool