Active NPI
Prentiss J Pemberton, LCSW
- Clinical Social Worker
- Anchorage, AK
National Provider Identifier
1902027832
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 732
- Practice address
- 4105 Tudor Centre Drive
Anchorage, AK 99508 - Phone
- (907) 565-4000
- Fax
- (907) 565-4011
- NPI assigned
- May 1, 2007
- Last updated
- Jul 9, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 732 | AK | Primary |
Addresses
Primary practice location
4105 Tudor Centre Drive
Anchorage, AK 99508
Mailing address
4105 Tudor Centre Drive
Anchorage, AK 99508
Phone (907) 565-4000
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| MH6578 | Medicaid | AK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Feb 24, 2025 through Feb 24, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 732 | AK | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177977600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1902027832",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4105 TUDOR CENTRE DRIVE",
"city": "ANCHORAGE",
"state": "AK",
"postal_code": "99508",
"telephone_number": "907-565-4000",
"fax_number": "907-565-4011"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4105 TUDOR CENTRE DRIVE",
"city": "ANCHORAGE",
"state": "AK",
"postal_code": "99508",
"telephone_number": "907-565-4000",
"fax_number": "907-565-4011"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEMBERTON",
"first_name": "PRENTISS",
"middle_name": "J",
"credential": "LCSW",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-05-01",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "AK",
"license": "732",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "MH6578",
"state": "AK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Anchorage, AK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.