Provider Demographics
NPI:1275161341
Name:PENN, ANDREW R (LMHC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:PENN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 48844
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-8844
Mailing Address - Country:US
Mailing Address - Phone:727-405-2450
Mailing Address - Fax:813-291-7788
Practice Address - Street 1:7402 N 56TH ST STE 355
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-7700
Practice Address - Country:US
Practice Address - Phone:727-405-2450
Practice Address - Fax:813-291-7788
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17862101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106080400Medicaid
FLMH17862OtherSTATE LICENSE