MEDICARE: CHEYENNE PECONGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-327478	IN

General Provider Information

NPI Number	:	1841005766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHEYENNE PECONGE

Provider Business Mailing Address
First Line	:	120 E MARKET ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3250
Country	:	US
Telephone Number	:	404-400-5004
Fax Number	:

Provider Business Practice Location Address
First Line	:	6506 COVINGTON RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7349
Country	:	US
Telephone Number	:	260-257-1735
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2025
Last Update Date	:	02/10/2025

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Directions to “ CHEYENNE PECONGE ” Practice Location

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