Provider Demographics
NPI:1578688859
Name:PELLETIER, SUSANNE (OTR)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 FARMINGTON AVE
Mailing Address - Street 2:SUITE 126
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE
Practice Address - Street 2:SUITE 126
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1909
Practice Address - Country:US
Practice Address - Phone:860-674-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002271225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT130002271CT03Medicare UPIN
CT130002271CT04Medicare UPIN