Provider Demographics
NPI:1235504671
Name:PENNINGTON GROUP FULL SPECTRUM SERVICES
Entity Type:Organization
Organization Name:PENNINGTON GROUP FULL SPECTRUM SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:757-472-1930
Mailing Address - Street 1:561 STERLING RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-2025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:561 STERLING RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-2025
Practice Address - Country:US
Practice Address - Phone:757-472-1930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000512103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty