Provider Demographics
NPI:1619728722
Name:PENCE, FREDERICK WILLIAM (LSW)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:PENCE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 PARKSIDE AVE N
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2609
Mailing Address - Country:US
Mailing Address - Phone:317-371-8717
Mailing Address - Fax:
Practice Address - Street 1:920 TOWN CENTER DR STE I80
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-4259
Practice Address - Country:US
Practice Address - Phone:484-224-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW130934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker