Provider Demographics
NPI:1538528906
Name:PENCE, CYNTHIA DEANN (PSYD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DEANN
Last Name:PENCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 W NORTH AVE
Mailing Address - Street 2:STE 303-A
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1422
Mailing Address - Country:US
Mailing Address - Phone:877-807-5120
Mailing Address - Fax:
Practice Address - Street 1:635 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6551
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009253103TC0700X
AZPSY005033103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ447808Medicaid