Provider Demographics
NPI:1205223468
Name:KATHRYN PENFOLD M., SC, LLC
Entity Type:Organization
Organization Name:KATHRYN PENFOLD M., SC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PENFOLD
Authorized Official - Suffix:
Authorized Official - Credentials:M, SC
Authorized Official - Phone:231-590-6242
Mailing Address - Street 1:820 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2466
Mailing Address - Country:US
Mailing Address - Phone:231-590-6242
Mailing Address - Fax:
Practice Address - Street 1:820 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2466
Practice Address - Country:US
Practice Address - Phone:231-590-6242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008173103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336325281OtherINDIVIDUAL NPI OF SOLE MEMBER