Provider Demographics
NPI:1265437495
Name:PENDLETON, EDWARD HAROLD (MA, LPC, LCDC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:HAROLD
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:MA, LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-0018
Mailing Address - Country:US
Mailing Address - Phone:936-328-5880
Mailing Address - Fax:936-328-5883
Practice Address - Street 1:2004 U S HIGHWAY 190 W
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9601
Practice Address - Country:US
Practice Address - Phone:936-328-5880
Practice Address - Fax:936-328-5883
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17475101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1508236-01Medicaid
TX2119098OtherCIGNA BEHAVIORAL HEALTH
TX7605707OtherAETNA
TXPENDL-0002OtherCOMPCARE PROVIDER ID
TX11451816OtherCAQH PROVIDER ID
TX551895OtherVALUE OPTIONS
TX719494000OtherMAGELLAN
TX6088LCOtherBLUECROSS/BLUESHIELD