1972645364 NPI number — RENAY LYNNE BEVINS PENCE LCSWR

Table of content: RENAY LYNNE BEVINS PENCE LCSWR (NPI 1972645364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972645364 NPI number — RENAY LYNNE BEVINS PENCE LCSWR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVINS PENCE
Provider First Name:
RENAY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSWR
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:
1972645364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW WINDSOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-561-4219
Provider Business Mailing Address Fax Number:
845-561-3644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
557 BLOOMING GROVE TPKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW WINDSOR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12553-7843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-561-4219
Provider Business Practice Location Address Fax Number:
845-561-3644
Provider Enumeration Date:
02/13/2007

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: 1041C0700X , with the licence number:  R0326471 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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