Provider Demographics
NPI:1558803718
Name:BAILEY, PENNY E
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:E
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 HOLLY AVE NE STE 4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2968
Mailing Address - Country:US
Mailing Address - Phone:505-596-0254
Mailing Address - Fax:
Practice Address - Street 1:9400 HOLLY AVE NE STE 4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2968
Practice Address - Country:US
Practice Address - Phone:505-596-0254
Practice Address - Fax:505-766-9367
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-08904104100000X
C-104051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker