Basic Information
| Provider Information | |||||||||
| NPI: | 1063878577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENCROFT PSYCHOLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 GRAND AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152181901 | ||||||||
| FaxNumber: | 5152746913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | JENISON | ||||||||
| AuthorizedOfficialFirstName: | DIANN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5152181901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 00679 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.