Provider Demographics
NPI:1699034041
Name:PENCEAL, VIVIAN O (TSHH, MSED)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:O
Last Name:PENCEAL
Suffix:
Gender:F
Credentials:TSHH, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25519 149TH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2812
Mailing Address - Country:US
Mailing Address - Phone:917-922-3668
Mailing Address - Fax:
Practice Address - Street 1:25519 149TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2812
Practice Address - Country:US
Practice Address - Phone:917-922-3668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215490235500000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No174400000XOther Service ProvidersSpecialist