1063878577 NPI number — PENCROFT PSYCHOLOGY ASSOCIATES LLC

Table of content: (NPI 1063878577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063878577 NPI number — PENCROFT PSYCHOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENCROFT PSYCHOLOGY ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1063878577
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2213 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50312-5305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-237-3974
Provider Business Mailing Address Fax Number:
515-883-2692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50312-5375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-218-1901
Provider Business Practice Location Address Fax Number:
515-274-6913
Provider Enumeration Date:
01/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JENISON
Authorized Official First Name:
DIANN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
515-218-1901

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  00679 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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