Provider Demographics
NPI:1588639033
Name:PERRENOUD, MARK WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:PERRENOUD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 W FULTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4347
Mailing Address - Country:US
Mailing Address - Phone:605-348-6500
Mailing Address - Fax:605-341-7409
Practice Address - Street 1:1818 W FULTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4347
Practice Address - Country:US
Practice Address - Phone:605-348-6500
Practice Address - Fax:605-341-7409
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD316103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550895Medicaid
SD6550895Medicaid