Provider Demographics
NPI:1922632215
Name:DEARTH-PENDLEY, GINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:DEARTH-PENDLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 E STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:KY
Mailing Address - Zip Code:40347-1112
Mailing Address - Country:US
Mailing Address - Phone:859-846-5745
Mailing Address - Fax:859-846-5745
Practice Address - Street 1:512 E STEPHENS ST
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:KY
Practice Address - Zip Code:40347-1112
Practice Address - Country:US
Practice Address - Phone:859-846-5745
Practice Address - Fax:859-846-5745
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY171875103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY171875OtherKENTUCKY BOARD OF EXAMINERS OF PSYCHOLOGY