Basic Information
| Provider Information | |||||||||
| NPI: | 1366985673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 412 LANDMARK RDG | ||||||||
| Address2: | |||||||||
| City: | CIBOLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781084407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108872580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4455 HORIZON HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782292258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2016 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.