Provider Demographics
NPI:1386029973
Name:PENNYWELL BEHAVIORAL HEALTH CENTER
Entity Type:Organization
Organization Name:PENNYWELL BEHAVIORAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:714-499-6232
Mailing Address - Street 1:5025 NELLIS OASIS LN APT 244
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-0770
Mailing Address - Country:US
Mailing Address - Phone:714-499-6232
Mailing Address - Fax:
Practice Address - Street 1:5025 NELLIS OASIS LN APT 244
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-0770
Practice Address - Country:US
Practice Address - Phone:714-499-6232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services