Provider Demographics
NPI:1568069193
Name:LYNN, PENELOPE J (LCSW)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:J
Last Name:LYNN
Suffix:
Gender:F
Credentials:LCSW
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 11082
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95406-1082
Mailing Address - Country:US
Mailing Address - Phone:707-889-3318
Mailing Address - Fax:
Practice Address - Street 1:1815 BODIE ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2497
Practice Address - Country:US
Practice Address - Phone:707-889-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA917551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical