Provider Demographics
NPI:1093446619
Name:RADFORD, PENNY MICHELLE
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MICHELLE
Last Name:RADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 WYNN DR NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-1961
Mailing Address - Country:US
Mailing Address - Phone:256-882-2457
Mailing Address - Fax:
Practice Address - Street 1:306 WYNN DR NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-1961
Practice Address - Country:US
Practice Address - Phone:256-882-2457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22218554106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician