Provider Demographics
NPI:1548429947
Name:PENNER, CLIFFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
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 1:200 E DEL MAR BLVD STE 126
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2551
Mailing Address - Country:US
Mailing Address - Phone:626-449-2525
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD
Practice Address - Street 2:STE 126
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2544
Practice Address - Country:US
Practice Address - Phone:626-449-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL3766103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist