Provider Demographics
NPI:1417518556
Name:PERNICANO PROFESSIONAL PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:PERNICANO PROFESSIONAL PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PERNICANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:210-278-4584
Mailing Address - Street 1:8800 VILLAGE DRIVE
Mailing Address - Street 2:STE 209
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217
Mailing Address - Country:US
Mailing Address - Phone:210-202-0100
Mailing Address - Fax:210-579-9705
Practice Address - Street 1:8800 VILLAGE DRIVE
Practice Address - Street 2:STE 209
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-202-0100
Practice Address - Fax:210-579-9705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3749426Medicaid