Provider Demographics
NPI:1114070406
Name:PELTIER, CORRIE JOESPH (LADC)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:JOESPH
Last Name:PELTIER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:STACY
Mailing Address - State:MN
Mailing Address - Zip Code:55079-0030
Mailing Address - Country:US
Mailing Address - Phone:651-408-7121
Mailing Address - Fax:
Practice Address - Street 1:31065 FOREST BLVD.
Practice Address - Street 2:
Practice Address - City:STACY
Practice Address - State:MN
Practice Address - Zip Code:55079
Practice Address - Country:US
Practice Address - Phone:650-408-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1032392-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility