Basic Information
| Provider Information | |||||||||
| NPI: | 1164552386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208849920 | ||||||||
| FaxNumber: | 5207920654 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857133353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208849920 | ||||||||
| FaxNumber: | 5207920654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TA0700X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TB0200X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TF0000X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Family | 103TP2701X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103T00000X | 1959 | AZ | X | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 505191 | 05 | AZ | MEDICAID |