Provider Demographics
NPI:1225150980
Name:PENN-LEON, VIDA LYNNE (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:VIDA
Middle Name:LYNNE
Last Name:PENN-LEON
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 HAVEN RD APT B12
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-3097
Mailing Address - Country:US
Mailing Address - Phone:240-457-9505
Mailing Address - Fax:240-337-8598
Practice Address - Street 1:1401 HAVEN RD APT B12
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-3097
Practice Address - Country:US
Practice Address - Phone:240-457-9505
Practice Address - Fax:240-337-8598
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10379OtherLCSW-C