Provider Demographics
NPI:1619860582
Name:PENCHAR, NATHANIEL MICHAEL
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:MICHAEL
Last Name:PENCHAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5303
Mailing Address - Country:US
Mailing Address - Phone:847-660-4574
Mailing Address - Fax:
Practice Address - Street 1:150 E DARTMOOR DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8710
Practice Address - Country:US
Practice Address - Phone:888-308-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician