Basic Information
| Provider Information | |||||||||
| NPI: | 1316288384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNYLANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10526 DUBNOFF WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916063921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187554950 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10526 DUBNOFF WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187554950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2013 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | CONTRERAS | ||||||||
| AuthorizedOfficialFirstName: | BERLIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8188924323 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.