Provider Demographics
NPI:1073677738
Name:PENDERGRASS, HAL I (MA)
Entity type:Individual
Prefix:
First Name:HAL
Middle Name:I
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12131 DORSETT RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2418
Mailing Address - Country:US
Mailing Address - Phone:314-298-0900
Mailing Address - Fax:314-298-9274
Practice Address - Street 1:12131 DORSETT RD
Practice Address - Street 2:SUITE 220
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2418
Practice Address - Country:US
Practice Address - Phone:314-298-0900
Practice Address - Fax:314-298-9274
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical