Provider Demographics
NPI:1497909428
Name:PENDERGAST, CAROLYN E (OT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:E
Last Name:PENDERGAST
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7750 DANNAHER DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-4039
Mailing Address - Country:US
Mailing Address - Phone:865-512-1140
Mailing Address - Fax:865-512-1141
Practice Address - Street 1:7750 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4039
Practice Address - Country:US
Practice Address - Phone:865-512-1140
Practice Address - Fax:865-512-1141
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2468225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4211295OtherBLUECROSS BLUESHIELD
TN1510678Medicaid
P00746470OtherRAILROAD MEDICARE
TN1510678Medicaid