Provider Demographics
NPI:1205264009
Name:PENROD, EDGAR (PCC-S)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:PENROD
Suffix:
Gender:M
Credentials:PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S PAINT ST STE 74
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3203
Mailing Address - Country:US
Mailing Address - Phone:740-771-9051
Mailing Address - Fax:
Practice Address - Street 1:12538 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:ROCKBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43149-9768
Practice Address - Country:US
Practice Address - Phone:740-974-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-0000896 SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional