Basic Information
| Provider Information | |||||||||
| NPI: | 1790144095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNY LANE CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Practice Location | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | FALLIE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | FACILITATOR/AV | ||||||||
| AuthorizedOfficialTelephone: | 6612664783 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 88669 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.