Provider Demographics
NPI:1487937447
Name:PENQUITE, MATTHEW WALTER
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WALTER
Last Name:PENQUITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 N BUSINESS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5204
Mailing Address - Country:US
Mailing Address - Phone:479-575-9476
Mailing Address - Fax:479-521-4971
Practice Address - Street 1:3715 N BUSINESS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5204
Practice Address - Country:US
Practice Address - Phone:479-575-9476
Practice Address - Fax:479-521-4971
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor