Provider Demographics
NPI:1720612500
Name:PENDERGRASS, MARCTIES
Entity Type:Individual
Prefix:
First Name:MARCTIES
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-6632
Mailing Address - Country:US
Mailing Address - Phone:843-550-7884
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND LOOP RD STE 3
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6180
Practice Address - Country:US
Practice Address - Phone:843-667-1905
Practice Address - Fax:843-667-1723
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7350101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional