Provider Demographics
NPI:1518304633
Name:PENBERTHY, KRISTIN R (LLBSW, QMHP, QMRP)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:R
Last Name:PENBERTHY
Suffix:
Gender:F
Credentials:LLBSW, QMHP, QMRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-3111
Mailing Address - Country:US
Mailing Address - Phone:989-631-2320
Mailing Address - Fax:989-631-3343
Practice Address - Street 1:2957 IMPERIAL DR
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-3111
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:989-631-3343
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086829104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker