Provider Demographics
NPI:1558436964
Name:PENLAND, ELIZABETH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:PENLAND
Suffix:
Gender:F
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4005 HIGH RESORT BLVD SE
Practice Address - Street 2:PMG RIO RANCHO HIGH RESORT 4005
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5906
Practice Address - Country:US
Practice Address - Phone:505-291-2402
Practice Address - Fax:505-291-2490
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0797103T00000X
103TA0700X, 103TC2200X, 103TF0200X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM101550OtherVALUE OPTIONS NUMBER
NM201046187OtherPRESBYTERIAN NUMBER