Provider Demographics
NPI:1578991105
Name:PELLETIER, EMILY L (LATC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:L
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 HORNISHER WAY APT 5105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-5603
Mailing Address - Country:US
Mailing Address - Phone:207-231-4107
Mailing Address - Fax:
Practice Address - Street 1:3533 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3604
Practice Address - Country:US
Practice Address - Phone:817-419-0303
Practice Address - Fax:833-626-1951
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1347917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000014829OtherBOC ATC
TX1347917OtherPHYSICAL THERAPY