Provider Demographics
NPI:1417637067
Name:PENDERGRASS, JULIANA NICOLE
Entity Type:Individual
Prefix:
First Name:JULIANA
Middle Name:NICOLE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SUNSET BLVD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677
Mailing Address - Country:US
Mailing Address - Phone:916-773-0211
Mailing Address - Fax:
Practice Address - Street 1:3101 SUNSET BLVD
Practice Address - Street 2:SUITE 1A
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677
Practice Address - Country:US
Practice Address - Phone:916-773-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician