Provider Demographics
NPI:1992776678
Name:PENDLETON, MARK G (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:PENDLETON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 47TH STREET SUITE E-3
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-5437
Mailing Address - Country:US
Mailing Address - Phone:303-444-6335
Mailing Address - Fax:303-443-9641
Practice Address - Street 1:3015 47TH STREET SUITE E-3
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-5437
Practice Address - Country:US
Practice Address - Phone:303-444-6335
Practice Address - Fax:303-443-9641
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO797103G00000X, 103TC0700X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07106081Medicaid
CO07106081Medicaid