Provider Demographics
NPI:1780416438
Name:PENROD, GARRETT MICHAEL (CPT)
Entity type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:MICHAEL
Last Name:PENROD
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 S PIERPONT DR APT 1076
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4651
Mailing Address - Country:US
Mailing Address - Phone:602-803-9210
Mailing Address - Fax:
Practice Address - Street 1:1941 S PIERPONT DR APT 1076
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4651
Practice Address - Country:US
Practice Address - Phone:602-803-9210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-29099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist