Basic Information
| Provider Information | |||||||||
| NPI: | 1538528906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENCE | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | DEANN | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1440 W NORTH AVE | ||||||||
| Address2: | STE 303-A | ||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601601422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778075120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850426551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 6022431235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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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 | 103TC0700X | 071009253 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY005033 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 447808 | 05 | AZ | MEDICAID |