Provider Demographics
NPI:1578231890
Name:PELLETIER, BRANDON LAURIER
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LAURIER
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 GAMAGE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-4573
Mailing Address - Country:US
Mailing Address - Phone:207-713-5589
Mailing Address - Fax:
Practice Address - Street 1:1155 LISBON ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5025
Practice Address - Country:US
Practice Address - Phone:207-783-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC204331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical