Provider Demographics
NPI:1558310102
Name:PELLETIER, GREG J (PHD LP)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:J
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7026
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:CENTRACARE HEALTH PLAZA
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-229-4977
Practice Address - Fax:320-656-7058
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2723103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical