Healthcare Provider Details

I. General information

NPI: 1649987371
Provider Name (Legal Business Name): ANTHONY PENISTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 BANDIT TRL
KELLER TX
76248-0111
US

IV. Provider business mailing address

4917 PARK OAK CT
FORT WORTH TX
76137-4186
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone: 817-470-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: