Provider Demographics
NPI:1124180161
Name:PENZEL, FREDERICK (PHD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:PENZEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MAURICE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1843
Mailing Address - Country:US
Mailing Address - Phone:631-385-0065
Mailing Address - Fax:631-424-4041
Practice Address - Street 1:755 NEW YORK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4240
Practice Address - Country:US
Practice Address - Phone:631-351-1729
Practice Address - Fax:631-424-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008782-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV30531Medicare ID - Type UnspecifiedPSYCHOLOGIST