MEDICARE: MARK WILLIAM PERRENOUD PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	316	SD
2	103TC1900X	Counseling Psychologist	316	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588639033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK WILLIAM PERRENOUD PH.D.

Provider Business Mailing Address
First Line	:	1818 W FULTON ST
Second Line	:	SUITE 201
City	:	RAPID CITY
State	:	SD
Zip	:	57702-4347
Country	:	US
Telephone Number	:	605-348-6500
Fax Number	:	605-341-7409

Provider Business Practice Location Address
First Line	:	1818 W FULTON ST
Second Line	:	SUITE 201
City	:	RAPID CITY
State	:	SD
Zip	:	57702-4347
Country	:	US
Telephone Number	:	605-348-6500
Fax Number	:	605-341-7409

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2006
Last Update Date	:	03/29/2012

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