Provider Demographics
NPI:1043660202
Name:MICHAEL PENDERGAST
Entity Type:Organization
Organization Name:MICHAEL PENDERGAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED INDEPENDENT SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:PENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-301-4526
Mailing Address - Street 1:1130 TEN ROD RD
Mailing Address - Street 2:BUILDING D, SUITE 307-C
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4161
Mailing Address - Country:US
Mailing Address - Phone:401-301-4526
Mailing Address - Fax:
Practice Address - Street 1:1130 TEN ROD RD
Practice Address - Street 2:BUILDING D, SUITE 307-C
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-301-4526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW013381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124181243OtherNPI