Provider Demographics
NPI:1184748014
Name:PELLETIER, KENNETH R (PHD, MD(HC))
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:PHD, MD(HC)
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Mailing Address - Street 1:5 COUNTRY OAK LN
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-2854
Mailing Address - Country:US
Mailing Address - Phone:925-932-7074
Mailing Address - Fax:925-838-3007
Practice Address - Street 1:5 COUNTRY OAK LN
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:CA
Practice Address - Zip Code:94507-2854
Practice Address - Country:US
Practice Address - Phone:925-932-7074
Practice Address - Fax:925-838-3007
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY4631103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist