Basic Information
| Provider Information | |||||||||
| NPI: | 1376643684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENDLEY | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 537 WINDSOR PARK DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374353588 | ||||||||
| FaxNumber: | 9374355865 | ||||||||
| Practice Location | |||||||||
| Address1: | 537 WINDSOR PARK DR | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374353588 | ||||||||
| FaxNumber: | 9374355865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1736 | OH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0355726 | 05 | OH | MEDICAID |