Provider Demographics
NPI:1073178513
Name:PENRY, HANNAH RAE
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:RAE
Last Name:PENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:RAE
Other - Last Name:MAUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1980 E WOODSMALL DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4937
Mailing Address - Country:US
Mailing Address - Phone:812-231-5269
Mailing Address - Fax:
Practice Address - Street 1:1050 W JOHNSON DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5508
Practice Address - Country:US
Practice Address - Phone:812-233-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-1936484103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300059985Medicaid