Provider Demographics
NPI:1376680694
Name:PENDERGRASS, ANTHONY B (EDD, LPC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:B
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:EDD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 1309
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:MO
Mailing Address - Zip Code:63957-9715
Mailing Address - Country:US
Mailing Address - Phone:573-223-3685
Mailing Address - Fax:573-223-7691
Practice Address - Street 1:306 N 2ND ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:MO
Practice Address - Zip Code:63957-1301
Practice Address - Country:US
Practice Address - Phone:573-223-7649
Practice Address - Fax:573-223-7691
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006038843101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor