Basic Information
| Provider Information | |||||||||
| NPI: | 1053688309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENDORF | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PLADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023793933 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 W NORFOLK AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023792030 | ||||||||
| FaxNumber: | 4023793933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 11/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | P-924 | NE | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 39189435426 | 05 | NE | MEDICAID |