Provider Demographics
NPI:1619153665
Name:PELLETIER, STACEY L (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:L
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BLAISDELL RD
Mailing Address - Street 2:
Mailing Address - City:STETSON
Mailing Address - State:ME
Mailing Address - Zip Code:04488-3013
Mailing Address - Country:US
Mailing Address - Phone:207-292-5599
Mailing Address - Fax:
Practice Address - Street 1:61 MAIN ST STE 31
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-8300
Practice Address - Country:US
Practice Address - Phone:207-299-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-20
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC136991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical