Provider Demographics
NPI:1619008836
Name:PELLETIER, HEATHER LEE (COTA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEE
Other - Last Name:VALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA
Mailing Address - Street 1:112 TORRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889
Mailing Address - Country:US
Mailing Address - Phone:401-737-9090
Mailing Address - Fax:
Practice Address - Street 1:10 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3222
Practice Address - Country:US
Practice Address - Phone:401-233-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOTA00218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist