Provider Demographics
NPI:1891264297
Name:PELLETIER, ANNALIESE ELIZABETH (MSW)
Entity Type:Individual
Prefix:
First Name:ANNALIESE
Middle Name:ELIZABETH
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ANNALIESE
Other - Middle Name:ELIZABETH
Other - Last Name:SLATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:844-807-3782
Practice Address - Street 1:1270 N NORTHWOOD CENTER CT
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2664
Practice Address - Country:US
Practice Address - Phone:208-664-8347
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor