Provider Demographics
NPI:1699799825
Name:PENCE, DANA J (PT)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:J
Last Name:PENCE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 616
Mailing Address - Street 2:723 EAST MAIN ST.
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701
Mailing Address - Country:US
Mailing Address - Phone:814-362-4621
Mailing Address - Fax:716-665-1160
Practice Address - Street 1:723 EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-3247
Practice Address - Country:US
Practice Address - Phone:814-363-4621
Practice Address - Fax:814-362-1066
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020254225100000X
PAPT013092L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02754218Medicaid