Provider Demographics
NPI:1285043984
Name:PELLETIER, ELLIS D (ATC)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:D
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BENNETT DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-2052
Mailing Address - Country:US
Mailing Address - Phone:207-498-6334
Mailing Address - Fax:
Practice Address - Street 1:118 BENNETT DR
Practice Address - Street 2:SUITE 140
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-2052
Practice Address - Country:US
Practice Address - Phone:207-498-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT5362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer