Provider Demographics
NPI:1720668429
Name:PELLETIER, GLORIA J (CISW, LISAC)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:CISW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N SIERRA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-3842
Mailing Address - Country:US
Mailing Address - Phone:928-412-4872
Mailing Address - Fax:
Practice Address - Street 1:219 N SIERRA VISTA DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-3842
Practice Address - Country:US
Practice Address - Phone:928-412-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LISAC-11825101YA0400X
AZLCSW-34081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)