Provider Demographics
NPI:1386278935
Name:PERNICANO PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:PERNICANO PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERNICANO
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:502-649-0697
Mailing Address - Street 1:8800 VILLAGE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5420
Mailing Address - Country:US
Mailing Address - Phone:210-202-0100
Mailing Address - Fax:
Practice Address - Street 1:8800 VILLAGE DR STE 209
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5420
Practice Address - Country:US
Practice Address - Phone:210-202-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-22
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200878100Medicaid