Provider Demographics
NPI:1992004188
Name:PELTON, GARY (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PELTON
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 1:502 OLD LYNCHBURG RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-6550
Mailing Address - Country:US
Mailing Address - Phone:434-972-1800
Mailing Address - Fax:
Practice Address - Street 1:2000 MICHIE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-2821
Practice Address - Country:US
Practice Address - Phone:434-970-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist