Provider Demographics
NPI:1497526792
Name:PENNYPACKER, BREANNA ROSE
Entity Type:Individual
Prefix:MS
First Name:BREANNA
Middle Name:ROSE
Last Name:PENNYPACKER
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 1:11176 CLARIDON TROY RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14707 S CHESHIRE ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:OH
Practice Address - Zip Code:44021-9601
Practice Address - Country:US
Practice Address - Phone:440-887-1100
Practice Address - Fax:440-887-1103
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.175932101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)