Provider Demographics
NPI:1942826813
Name:PENDERGAST, DAVID LEO (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEO
Last Name:PENDERGAST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:L
Other - Last Name:PENDERGAST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:36 A ST UNIT 6C
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1870
Mailing Address - Country:US
Mailing Address - Phone:616-910-8915
Mailing Address - Fax:
Practice Address - Street 1:36 A ST UNIT 6C
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-1870
Practice Address - Country:US
Practice Address - Phone:616-910-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4581-PY-PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist