Provider Demographics
NPI:1669973533
Name:PELOQUIN, MATHIEU RYAN (CRC)
Entity type:Individual
Prefix:
First Name:MATHIEU
Middle Name:RYAN
Last Name:PELOQUIN
Suffix:
Gender:M
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SUTTON PL APT 2
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-1433
Mailing Address - Country:US
Mailing Address - Phone:401-263-8993
Mailing Address - Fax:
Practice Address - Street 1:140 HIGH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1442
Practice Address - Country:US
Practice Address - Phone:413-495-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952693142Medicaid