1265437495 NPI number — MR. EDWARD HAROLD PENDLETON MA, LPC, LCDC

Table of content: (NPI 1407675895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265437495 NPI number — MR. EDWARD HAROLD PENDLETON MA, LPC, LCDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENDLETON
Provider First Name:
EDWARD
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, LCDC
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:
1265437495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVINGSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77351-0018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-328-5880
Provider Business Mailing Address Fax Number:
936-328-5883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 U S HIGHWAY 190 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVINGSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77351-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-328-5880
Provider Business Practice Location Address Fax Number:
936-328-5883
Provider Enumeration Date:
06/15/2005

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: 101Y00000X , with the licence number:  17475 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1508236-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2119098 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7605707 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PENDL-0002 . This is a "COMPCARE PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 11451816 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 551895 . This is a "VALUE OPTIONS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 719494000 . This is a "MAGELLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 6088LC . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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