Provider Demographics
NPI:1710004163
Name:PENGELLY, EARLYN DOROTHY (MA, MS)
Entity Type:Individual
Prefix:MS
First Name:EARLYN
Middle Name:DOROTHY
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-2309
Mailing Address - Country:US
Mailing Address - Phone:507-388-5801
Mailing Address - Fax:507-388-2715
Practice Address - Street 1:430 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-2309
Practice Address - Country:US
Practice Address - Phone:507-388-5801
Practice Address - Fax:507-388-2715
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1114103TC0700X
MN41371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57786PEOtherBLUE CROSS BLUE SHIELD
MN120002OtherUCARE INSURANCE
MN6120605OtherMEDICA, UBH
MNHP28654OtherHEALTH PARTNERS