Basic Information
| Provider Information | |||||||||
| NPI: | 1023194925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLEGRINO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 FOREST ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284407 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 068-0000170 | VT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1007038 | 05 | VT | MEDICAID | 19428 | 01 | VT | BLUE CROSS | OTHER | 14Y001678VT01 | 01 | VT | ANTHEM | OTHER | 1041581 | 01 | VT | CIGNA | OTHER |