Provider Demographics
NPI:1538312178
Name:PENDERGRASS, KATHLEEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:8024 FLAG TAIL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-1954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:253-278-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD04939103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program