Provider Demographics
NPI:1245414440
Name:PELLITTERI, MARY MASCOLO (LADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MASCOLO
Last Name:PELLITTERI
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DIVISION STREET
Mailing Address - Street 2:GRIFFIN HOSPITAL
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418
Mailing Address - Country:US
Mailing Address - Phone:203-732-7550
Mailing Address - Fax:203-732-1550
Practice Address - Street 1:130 DIVISION STREET
Practice Address - Street 2:GRIFFIN HOSPITAL
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418
Practice Address - Country:US
Practice Address - Phone:203-732-7550
Practice Address - Fax:203-732-1550
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00364101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00364OtherLICENSE NUMBER