Provider Demographics
NPI:1679082366
Name:PELHAM, MICHEAL LAVELL III
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:LAVELL
Last Name:PELHAM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 EMERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2354
Mailing Address - Country:US
Mailing Address - Phone:202-847-7555
Mailing Address - Fax:
Practice Address - Street 1:1414 SARATOGA AVE NE APT 4
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1919
Practice Address - Country:US
Practice Address - Phone:202-440-7389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty