Provider Demographics
NPI:1528539780
Name:PENDRAK, DANIEL SHERMAN
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SHERMAN
Last Name:PENDRAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 STEFANI RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7795
Mailing Address - Country:US
Mailing Address - Phone:850-607-6910
Mailing Address - Fax:850-607-6932
Practice Address - Street 1:5330 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-8015
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:850-607-6932
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71433106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician