Basic Information
| Provider Information | |||||||||
| NPI: | 1720463086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNEKAMP | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | FASANELLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FASANELLA | ||||||||
| OtherFirstName: | CECILIA | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10839 QUARRY PARK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782334681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102576260 | ||||||||
| FaxNumber: | 2104518058 | ||||||||
| Practice Location | |||||||||
| Address1: | 10839 QUARRY PARK | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782334681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1025762602 | ||||||||
| FaxNumber: | 2104518058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1470 | ID | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 116910 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.