Basic Information
| Provider Information | |||||||||
| NPI: | 1245209329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNINGTON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2004024505 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 2042-C | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 11583081 | 01 | MO | CAQH PROVIDER ID | OTHER | 2042-C | 01 | AR | LCSW | OTHER | 2004024505 | 01 | MO | CLINICAL SOCIAL WORKER | OTHER | 490048709 | 05 | MO | MEDICAID |