Healthcare Provider Details

I. General information

NPI: 1538528906
Provider Name (Legal Business Name): CYNTHIA DEANN PENCE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 E BASELINE RD
PHOENIX AZ
85042-6551
US

IV. Provider business mailing address

1440 W NORTH AVE STE 303-A
MELROSE PARK IL
60160-1422
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax: 602-243-1235
Mailing address:
  • Phone: 877-807-5120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009253
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY005033
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: