Healthcare Provider Details

I. General information

NPI: 1053418475
Provider Name (Legal Business Name): PENNIE R. DEXTER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PENNIE R. CARRELL DEXTER PH.D.

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 W. 2ND ST.
NEDERLAND CO
80466
US

IV. Provider business mailing address

PO BOX 1102 KEYSTONE COUNSELING, LLC
NEDERLAND CO
80466-1102
US

V. Phone/Fax

Practice location:
  • Phone: 303-601-3416
  • Fax: 303-258-9356
Mailing address:
  • Phone: 303-601-3416
  • Fax: 303-258-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY2854
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: