Provider Demographics
NPI:1932649308
Name:ZADDACK, PENNY S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:S
Last Name:ZADDACK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 W PINNACLE PEAK RD
Mailing Address - Street 2:SUITE 201-23
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1201
Mailing Address - Country:US
Mailing Address - Phone:602-410-5845
Mailing Address - Fax:
Practice Address - Street 1:2155 W PINNACLE PEAK RD
Practice Address - Street 2:SUITE 201-23
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1201
Practice Address - Country:US
Practice Address - Phone:602-410-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4829103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist