Provider Demographics
NPI:1053418475
Name:DEXTER, PENNIE R (PHD)
Entity type:Individual
Prefix:DR
First Name:PENNIE
Middle Name:R
Last Name:DEXTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:PENNIE
Other - Middle Name:R CARRELL
Other - Last Name:DEXTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1102
Mailing Address - Street 2:KEYSTONE COUNSELING, LLC
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-1102
Mailing Address - Country:US
Mailing Address - Phone:303-601-3416
Mailing Address - Fax:303-258-9356
Practice Address - Street 1:159 W. 2ND ST.
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:CO
Practice Address - Zip Code:80466
Practice Address - Country:US
Practice Address - Phone:303-601-3416
Practice Address - Fax:303-258-9356
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY2854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11572163OtherCAQH UNIVERSAL CREDENTIAL