Basic Information
| Provider Information | |||||||||
| NPI: | 1790450823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNICK | ||||||||
| FirstName: | ADRIAN | ||||||||
| MiddleName: | ELISSE | ||||||||
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| Credential: | B.S, RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 RIVERSTONE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774594723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3463684412 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4722 RIVERSTONE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774594723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3463684412 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2021 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | TX | Y |
No ID Information.