Provider Demographics
NPI:1225136880
Name:PENNINGTON, MARTIN B II (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:B
Last Name:PENNINGTON
Suffix:II
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 MONTEREY LN
Mailing Address - Street 2:APARTMENT D
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5340
Mailing Address - Country:US
Mailing Address - Phone:949-510-3845
Mailing Address - Fax:
Practice Address - Street 1:101 AVENIDA SERRA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4760
Practice Address - Country:US
Practice Address - Phone:949-510-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB26001103TA0400X
CAPSB26011103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical