Provider Demographics
NPI:1356487284
Name:MACDONALD, PENNY SUE KIMBALL (MS LADC LCMHC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:SUE KIMBALL
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MS LADC LCMHC
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS LADC LCMHC
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05863
Mailing Address - Country:US
Mailing Address - Phone:802-748-8904
Mailing Address - Fax:
Practice Address - Street 1:1129 MAIN ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000130101YA0400X
VT068-0000603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health