Provider Demographics
NPI:1568533628
Name:PELLETIER, ROBIN LYSANE (PT, MPT)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:LYSANE
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-1936
Mailing Address - Country:US
Mailing Address - Phone:360-258-2726
Mailing Address - Fax:
Practice Address - Street 1:106 E 15TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3401
Practice Address - Country:US
Practice Address - Phone:360-750-5850
Practice Address - Fax:360-750-7244
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8335184Medicaid