Provider Demographics
NPI:1790113454
Name:PENDER, ARCHIE (LCAS-A)
Entity Type:Individual
Prefix:
First Name:ARCHIE
Middle Name:
Last Name:PENDER
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4354 PINE TREE CT
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-8590
Mailing Address - Country:US
Mailing Address - Phone:252-363-1675
Mailing Address - Fax:252-206-5778
Practice Address - Street 1:3709 NASH ST NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1127
Practice Address - Country:US
Practice Address - Phone:252-206-5799
Practice Address - Fax:252-206-5778
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-21378101YA0400X
NCP0102091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical