Provider Demographics
NPI:1124707617
Name:PELTON, MARY ALICE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:PELTON
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 1:505 W PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-1849
Mailing Address - Country:US
Mailing Address - Phone:330-414-0359
Mailing Address - Fax:
Practice Address - Street 1:320 MARKET ST
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2153
Practice Address - Country:US
Practice Address - Phone:740-314-5339
Practice Address - Fax:740-314-5527
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
OHAPS.005502175T00000X
OHCDCA.190212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer Specialist