Provider Demographics
NPI:1376643684
Name:PENDLEY, LARRY M (MS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:M
Last Name:PENDLEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 WINDSOR PARK DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4112
Mailing Address - Country:US
Mailing Address - Phone:937-435-3588
Mailing Address - Fax:937-435-5865
Practice Address - Street 1:537 WINDSOR PARK DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4112
Practice Address - Country:US
Practice Address - Phone:937-435-3588
Practice Address - Fax:937-435-5865
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1736103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355726Medicaid
OHPECP01211Medicare ID - Type UnspecifiedMEDICARE
OH0355726Medicaid