1962506493 NPI number — DR. RENEE MARIE PENTICOFF PSY.D.

Table of content: DR. RENEE MARIE PENTICOFF PSY.D. (NPI 1962506493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962506493 NPI number — DR. RENEE MARIE PENTICOFF PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENTICOFF
Provider First Name:
RENEE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

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:
1962506493
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25334
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-0334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-255-6678
Provider Business Mailing Address Fax Number:
651-501-6091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 WOODDALE DR
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-2940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-255-6678
Provider Business Practice Location Address Fax Number:
651-501-6091
Provider Enumeration Date:
09/13/2006

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: 103TC0700X , with the licence number:  LP 4060 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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