Provider Demographics
NPI:1609189752
Name:PELLETIER, JOANNE RUTH
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:RUTH
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 NORTH BROADWAY
Mailing Address - Street 2:ANDRUS CHILDREN'S CENTER
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1108
Mailing Address - Country:US
Mailing Address - Phone:914-965-3700
Mailing Address - Fax:
Practice Address - Street 1:19 GREENRIDGE AVENUE
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER MENTAL HEALTH DIVISION
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605
Practice Address - Country:US
Practice Address - Phone:914-949-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940OtherAGENCY MEDICAID PROVIDER ID
NY1285628552OtherAGENCY NPI#
NYWVE061OtherAGENCY MEDICARE ID #