Provider Demographics
NPI:1619728722
Name:PENCE, FREDERICK WILLIAM (LSW)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:PENCE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746722
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6722
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:3621 ARAMINGO AVE STE 5C
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4607
Practice Address - Country:US
Practice Address - Phone:215-444-7472
Practice Address - Fax:215-979-6726
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW130934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker