Basic Information
| Provider Information | |||||||||
| NPI: | 1598437550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNEY | ||||||||
| FirstName: | MIKAYLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 TYVOLA RD STE 126 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282173539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 GATEWAY CENTRE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275609669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2021 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 12153221 | NC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.