Provider Demographics
NPI:1134634017
Name:PENN, KEVIN MITCHELL
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MITCHELL
Last Name:PENN
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 1:2975 TREAT BLVD STE C5
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-3631
Mailing Address - Country:US
Mailing Address - Phone:925-324-7002
Mailing Address - Fax:925-608-6741
Practice Address - Street 1:2975 TREAT BLVD STE C5
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3631
Practice Address - Country:US
Practice Address - Phone:925-324-7002
Practice Address - Fax:925-608-6741
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health