Provider Demographics
NPI:1174276570
Name:PENTON, ANTHONY (LPC-IT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PENTON
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FOREST AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4165
Mailing Address - Country:US
Mailing Address - Phone:920-933-9256
Mailing Address - Fax:
Practice Address - Street 1:17 FOREST AVE STE 15
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4165
Practice Address - Country:US
Practice Address - Phone:920-933-9256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10222-125101YP2500X
WI5024-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty