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General NPI Number Information
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NPI Number | 1619860582
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Entity Type | Individual
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Provider Name | NATHANIEL MICHAEL PENCHAR
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Gender | Male
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Dates
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Enumeration Date | 05/30/2025
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Last Update Date | 05/30/2025
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Provider Practice Location Address
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Address Line | 150 E DARTMOOR DR
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-8710
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Country | US
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Telephone | 888-308-3728
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Fax |
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Provider Business Mailing Address
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Address Line | 1427 ESSEX ST
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City | ALGONQUIN
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State | IL
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Zip | 60102-5303
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Country | US
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Telephone | 847-660-4574
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State | IL
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