Provider Demographics
NPI:1720043722
Name:PENTICUFF, MICHAEL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:PENTICUFF
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 1:1707 ENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-3308
Mailing Address - Country:US
Mailing Address - Phone:512-454-9300
Mailing Address - Fax:512-454-9370
Practice Address - Street 1:1707 ENFIELD RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-3308
Practice Address - Country:US
Practice Address - Phone:512-454-9300
Practice Address - Fax:512-454-9370
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-5038103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0362865-01Medicaid
TX0362865-01Medicaid