Healthcare Provider Details

I. General information

NPI: 1538312178
Provider Name (Legal Business Name): KATHLEEN PENDERGRASS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN HAINES PSY.D.

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 24TH ST
FORT LEE VA
23801-1716
US

IV. Provider business mailing address

8024 FLAG TAIL DR
MIDLOTHIAN VA
23112-1954
US

V. Phone/Fax

Practice location:
  • Phone: 253-278-2607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number04939
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: