Provider Demographics
NPI:1275200966
Name:PENN, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:PENN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MERCY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-0296
Mailing Address - Country:US
Mailing Address - Phone:119-377-1231
Mailing Address - Fax:
Practice Address - Street 1:149 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-0296
Practice Address - Country:US
Practice Address - Phone:119-377-1231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty