Provider Demographics
NPI:1245841543
Name:PEMBERTON, ANNA (MED, EDS)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 ORION ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8375
Mailing Address - Country:US
Mailing Address - Phone:330-966-1007
Mailing Address - Fax:
Practice Address - Street 1:250 ORION ST NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8375
Practice Address - Country:US
Practice Address - Phone:330-966-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH583103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool