Provider Demographics
NPI:1790874733
Name:BELLETTIRIE, GERALD F (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:F
Last Name:BELLETTIRIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2351
Mailing Address - Country:US
Mailing Address - Phone:215-362-1280
Mailing Address - Fax:
Practice Address - Street 1:920 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2351
Practice Address - Country:US
Practice Address - Phone:215-362-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003646-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABE189307OtherBLUE SHIELD
PABE189307OtherBLUE SHIELD