Provider Demographics
NPI:1114599198
Name:PENN 11, MELVIN JEFFERY
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:JEFFERY
Last Name:PENN 11
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 RED CLAY RD APT 303
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2369
Mailing Address - Country:US
Mailing Address - Phone:202-790-8903
Mailing Address - Fax:
Practice Address - Street 1:275 RED CLAY RD APT 303
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-2369
Practice Address - Country:US
Practice Address - Phone:202-790-8903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-21-174539106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician