Provider Demographics
NPI:1013283670
Name:MARK W. PERRENOUD PH.D. INC.
Entity Type:Organization
Organization Name:MARK W. PERRENOUD PH.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PERRENOUD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:605-348-6500
Mailing Address - Street 1:1818 WEST FULTON
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-4347
Mailing Address - Country:US
Mailing Address - Phone:605-348-6500
Mailing Address - Fax:605-341-7409
Practice Address - Street 1:1818 WEST FULTON
Practice Address - Street 2:SUITE 201
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-4347
Practice Address - Country:US
Practice Address - Phone:605-348-6500
Practice Address - Fax:605-341-7409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD316261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550895Medicaid
SD6550895Medicaid