1992489777 NPI number — MR. LEE FREEMAN PELLETIER MA, MDIV

Table of content: MR. LEE FREEMAN PELLETIER MA, MDIV (NPI 1992489777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992489777 NPI number — MR. LEE FREEMAN PELLETIER MA, MDIV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLETIER
Provider First Name:
LEE
Provider Middle Name:
FREEMAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, MDIV
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992489777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 REID ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PLAIN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13339-1336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-490-9199
Provider Business Mailing Address Fax Number:
518-309-6884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 REID ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PLAIN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13339-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-490-9199
Provider Business Practice Location Address Fax Number:
518-309-6884
Provider Enumeration Date:
06/13/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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