Provider Demographics
NPI:1225172471
Name:SEARS, PENNI LANE
Entity Type:Individual
Prefix:
First Name:PENNI
Middle Name:LANE
Last Name:SEARS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 NEVADA AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-4114
Mailing Address - Country:US
Mailing Address - Phone:505-496-8174
Mailing Address - Fax:
Practice Address - Street 1:1600 THORPE RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-9776
Practice Address - Country:US
Practice Address - Phone:505-496-8174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2008-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0106931106H00000X
NM0111001101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)