Provider Demographics
NPI:1578690772
Name:PELOSI, ROBERT A (NCC, LCMHC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:PELOSI
Suffix:
Gender:M
Credentials:NCC, LCMHC
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 416
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05363-0416
Mailing Address - Country:US
Mailing Address - Phone:802-464-0543
Mailing Address - Fax:802-464-0543
Practice Address - Street 1:610 VERMONT RTE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05342
Practice Address - Country:US
Practice Address - Phone:802-368-2220
Practice Address - Fax:802-368-2220
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004004101YM0800X
VT068.0089265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT600499496OtherBCBS
VT1014830Medicaid