Provider Demographics
NPI:1548869712
Name:PENDLETON COUNSELING CENTER
Entity type:Organization
Organization Name:PENDLETON COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:PENDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-201-4111
Mailing Address - Street 1:403 OLD TOWN CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3628
Mailing Address - Country:US
Mailing Address - Phone:601-201-4111
Mailing Address - Fax:601-825-1793
Practice Address - Street 1:403 OLD TOWN CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3628
Practice Address - Country:US
Practice Address - Phone:601-201-4111
Practice Address - Fax:601-825-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06635891Medicaid