Provider Demographics
NPI:1235666405
Name:PELLETTE, COLLEEN DORIS KLEINBERG (MSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:DORIS KLEINBERG
Last Name:PELLETTE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:DORIS
Other - Last Name:KLEINBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3666 HAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1531
Mailing Address - Country:US
Mailing Address - Phone:484-278-3725
Mailing Address - Fax:
Practice Address - Street 1:3666 HAYWOOD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1531
Practice Address - Country:US
Practice Address - Phone:484-278-3725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0201781041C0700X
CAASW68862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACW020178OtherLCSW LICENSE NUMBER