Healthcare Provider Details

I. General information

NPI: 1376680694
Provider Name (Legal Business Name): ANTHONY B PENDERGRASS ED.D., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N 2ND ST
PIEDMONT MO
63957-1301
US

IV. Provider business mailing address

RR 1 BOX 1309
PIEDMONT MO
63957-9715
US

V. Phone/Fax

Practice location:
  • Phone: 573-223-7649
  • Fax: 573-223-7691
Mailing address:
  • Phone: 573-223-3685
  • Fax: 573-223-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2006038843
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: