Provider Demographics
NPI:1174011688
Name:PELLEGRINI, AUDRA
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:PELLEGRINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:A. AJAY
Other - Middle Name:
Other - Last Name:PELLEGRINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:120 SE EVERETT MALL WAY APT 127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3281
Mailing Address - Country:US
Mailing Address - Phone:205-458-3104
Mailing Address - Fax:
Practice Address - Street 1:18311 BOTHELL EVERETT HWY STE 260
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-5233
Practice Address - Country:US
Practice Address - Phone:206-437-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst