Provider Demographics
NPI:1033496369
Name:PENNOCK, TANYA
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WHITEHALL RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1447
Mailing Address - Country:US
Mailing Address - Phone:518-462-7241
Mailing Address - Fax:
Practice Address - Street 1:108 WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209-1447
Practice Address - Country:US
Practice Address - Phone:518-462-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool