Provider Demographics
NPI:1134498777
Name:PENNY, LISA ANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:PENNY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 VIA MARINA
Mailing Address - Street 2:#501K
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5242
Mailing Address - Country:US
Mailing Address - Phone:310-990-9164
Mailing Address - Fax:310-306-8018
Practice Address - Street 1:13160 MINDANAO WAY
Practice Address - Street 2:#300
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6358
Practice Address - Country:US
Practice Address - Phone:310-990-9164
Practice Address - Fax:310-306-8018
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79290106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist