Provider Demographics
NPI:1386764694
Name:PERNELL, EUGENE JR (PHD)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:
Last Name:PERNELL
Suffix:JR
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 1:5031 PARK LAKE ROAD
Mailing Address - Street 2:MERIDIAN PROFESSIONAL PSYCHOLOGICAL CONSULTANTS
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3835
Mailing Address - Country:US
Mailing Address - Phone:517-332-0811
Mailing Address - Fax:517-332-4452
Practice Address - Street 1:5031 PARK LAKE ROAD
Practice Address - Street 2:MERIDIAN PROFESSIONAL PSYCHOLOGICAL CONSULTANTS
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3835
Practice Address - Country:US
Practice Address - Phone:517-332-0811
Practice Address - Fax:517-332-4452
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OC34590Medicare ID - Type Unspecified