Provider Demographics
NPI:1225431224
Name:PENN-ELLINGTON, LOLA
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:PENN-ELLINGTON
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 1:1717 N CROSKEY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3015
Mailing Address - Country:US
Mailing Address - Phone:267-270-7277
Mailing Address - Fax:
Practice Address - Street 1:1717 N CROSKEY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3015
Practice Address - Country:US
Practice Address - Phone:267-270-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor