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General NPI Number Information
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NPI Number | 1588896310
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Entity Type | Organization
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Legal Business Name | PENTICOFF COMMUNITY COUNSELING, INC.
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Dates
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Enumeration Date | 08/12/2009
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Last Update Date | 08/12/2009
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Provider Practice Location Address
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Address Line | 1818 WOODDALE DR STE 204
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City | WOODBURY
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State | MN
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Zip | 55125-2983
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Country | US
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Telephone | 651-255-6678
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Fax | 651-501-6091
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Provider Business Mailing Address
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Address Line | PO BOX 25334
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City | WOODBURY
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State | MN
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Zip | 55125-0334
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Country | US
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Telephone | 651-255-6678
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Fax | 651-501-6091
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Authorized Official
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Title or Position | OWNER, PRESIDENT
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Name | DR. RENEE MARIE PENTICOFF
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Credential | PSY.D.
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Telephone | 651-255-6678
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP-4060
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License Number State | MN
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