Provider Demographics
NPI:1558857623
Name:PARKS-PENWELL, MARY GRACE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:PARKS-PENWELL
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 1:1169 EASTERN PKWY STE G1111
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1462
Mailing Address - Country:US
Mailing Address - Phone:502-242-9091
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY STE G1111
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1462
Practice Address - Country:US
Practice Address - Phone:502-242-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician