Provider Demographics
NPI:1518081462
Name:PENNER, DAVID R (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:PENNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60014
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98160-0014
Mailing Address - Country:US
Mailing Address - Phone:425-640-9777
Mailing Address - Fax:425-640-5122
Practice Address - Street 1:21907 64TH AVE W
Practice Address - Street 2:SUITE 220
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:425-640-9777
Practice Address - Fax:425-640-5122
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00000896103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8866806Medicare UPIN
WAG000108490Medicare UPIN