Provider Demographics
NPI:1740626399
Name:PELLERITO, JOSEPH M JR (PHD, OTRL)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:PELLERITO
Suffix:JR
Gender:M
Credentials:PHD, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7469 HAFLINGER CIR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3917
Mailing Address - Country:US
Mailing Address - Phone:313-643-7925
Mailing Address - Fax:
Practice Address - Street 1:18530 MACK AVE STE 235
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3254
Practice Address - Country:US
Practice Address - Phone:313-643-7925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001766171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor