Provider Demographics
NPI:1124560735
Name:PEHLE, MARK (MA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PEHLE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 HEBERT RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:VT
Mailing Address - Zip Code:05679-9109
Mailing Address - Country:US
Mailing Address - Phone:802-236-8228
Mailing Address - Fax:
Practice Address - Street 1:322 HEBERT RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:VT
Practice Address - Zip Code:05679-9109
Practice Address - Country:US
Practice Address - Phone:802-236-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0110488101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health