Provider Demographics
NPI:1033392410
Name:HEATH, PENNIE SMITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PENNIE
Middle Name:SMITH
Last Name:HEATH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 AUTUMN AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-5310
Mailing Address - Country:US
Mailing Address - Phone:901-725-2724
Mailing Address - Fax:901-725-2724
Practice Address - Street 1:1840 AUTUMN AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-5310
Practice Address - Country:US
Practice Address - Phone:901-725-2724
Practice Address - Fax:901-725-2724
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-09
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000036391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4173199OtherBCBS OF TENNESSEE
P00456850OtherRAILROAD MEDICARE
TN3920071Medicaid
P00456850OtherRAILROAD MEDICARE