Provider Demographics
NPI:1538102959
Name:PENNELL, ROBERT CLARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CLARK
Last Name:PENNELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:CLARK
Other - Last Name:PENNELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3959 S NOVA RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9278
Mailing Address - Country:US
Mailing Address - Phone:386-761-2390
Mailing Address - Fax:386-761-3256
Practice Address - Street 1:3959 S NOVA RD
Practice Address - Street 2:SUITE 5
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9278
Practice Address - Country:US
Practice Address - Phone:386-761-2390
Practice Address - Fax:386-761-3256
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3855103T00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6529Medicare UPIN