Provider Demographics
NPI:1376164434
Name:PENN, ANGELA MAIJA-LIISA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MAIJA-LIISA
Last Name:PENN
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 1:11415 LONE PINE CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-0482
Mailing Address - Country:US
Mailing Address - Phone:540-538-5263
Mailing Address - Fax:
Practice Address - Street 1:11 HOPE RD STE 215
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7287
Practice Address - Country:US
Practice Address - Phone:540-225-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VARBT-20-119255106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician