Provider Demographics
NPI:1922377662
Name:PENDLETON, LINDA FAYE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:FAYE
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 OLD TOWN CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3628
Mailing Address - Country:US
Mailing Address - Phone:601-825-1793
Mailing Address - Fax:
Practice Address - Street 1:403 OLD TOWN CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3628
Practice Address - Country:US
Practice Address - Phone:601-825-1793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC20851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS318002YJ5DMedicare PIN