Provider Demographics
NPI:1194864686
Name:PELLETIER, AMANDA ELAINE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELAINE
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:ELAINE
Other - Last Name:WRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:1011 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-5061
Practice Address - Country:US
Practice Address - Phone:401-432-1000
Practice Address - Fax:401-432-1500
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1132011041C0700X
RIISW016911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical