Provider Demographics
NPI:1396042206
Name:PELLETREAU, PAUL (LCSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PELLETREAU
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4268
Mailing Address - Street 2:319 TARPON STREET P.O. BOX 4268
Mailing Address - City:ANNA MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34216-4268
Mailing Address - Country:US
Mailing Address - Phone:941-778-7402
Mailing Address - Fax:
Practice Address - Street 1:4236 59TH ST W
Practice Address - Street 2:4236 59TH STREET WEST
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-6664
Practice Address - Country:US
Practice Address - Phone:941-794-6617
Practice Address - Fax:941-795-7536
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-13
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 30861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5659AMedicare PIN