Provider Demographics
NPI:1043327455
Name:PENENO, JANICE A (LICSW, BCD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:A
Last Name:PENENO
Suffix:
Gender:F
Credentials:LICSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 CODDINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4511
Mailing Address - Country:US
Mailing Address - Phone:617-867-9227
Mailing Address - Fax:617-328-6277
Practice Address - Street 1:67 CODDINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4511
Practice Address - Country:US
Practice Address - Phone:617-867-9227
Practice Address - Fax:617-328-6277
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10188191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859382Medicaid
MAP06709OtherBLUE CROSS BLUE SHIELD
MA1859382Medicaid