Provider Demographics
NPI:1841894516
Name:PENTECOST, DARBY MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:DARBY
Middle Name:MICHAEL
Last Name:PENTECOST
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:MICHAEL
Other - Last Name:PENTECOST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:551 S HOLLAND LN
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2007
Mailing Address - Country:US
Mailing Address - Phone:316-796-5776
Mailing Address - Fax:
Practice Address - Street 1:551 S HOLLAND LN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2007
Practice Address - Country:US
Practice Address - Phone:316-796-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1692101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)