Provider Demographics
NPI:1124357082
Name:TREVITHICK, PENNY (CBS)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:TREVITHICK
Suffix:
Gender:F
Credentials:CBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 145
Mailing Address - Street 2:
Mailing Address - City:HYGIENE
Mailing Address - State:CO
Mailing Address - Zip Code:80533
Mailing Address - Country:US
Mailing Address - Phone:303-579-7003
Mailing Address - Fax:
Practice Address - Street 1:8380 HYGIENE RD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503
Practice Address - Country:US
Practice Address - Phone:303-579-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5095BF174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5095BCOtherNATIONAL THERAPIES CERTICICATION BOARD