Provider Demographics
NPI:1073797049
Name:PERGAMENT, PENNY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:A
Last Name:PERGAMENT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5744 ELLIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2412
Mailing Address - Country:US
Mailing Address - Phone:612-823-4373
Mailing Address - Fax:612-823-4373
Practice Address - Street 1:5744 ELLIOT AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2412
Practice Address - Country:US
Practice Address - Phone:612-823-4373
Practice Address - Fax:612-823-4373
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical