Provider Demographics
NPI:1154847101
Name:PENDERGAST, DEVIN WILLIAM
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:WILLIAM
Last Name:PENDERGAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 MALL RING CIR STE 215
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6691
Mailing Address - Country:US
Mailing Address - Phone:702-547-6971
Mailing Address - Fax:
Practice Address - Street 1:731 MALL RING CIR STE 215
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6691
Practice Address - Country:US
Practice Address - Phone:702-547-6971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-17106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician