Provider Demographics
NPI:1568559391
Name:PENNER, IRVIN ROY (LSCSW MSW)
Entity Type:Individual
Prefix:MR
First Name:IRVIN
Middle Name:ROY
Last Name:PENNER
Suffix:
Gender:M
Credentials:LSCSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11521 WILSHIRE TERRACE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-4337
Mailing Address - Country:US
Mailing Address - Phone:316-681-3840
Mailing Address - Fax:316-684-5136
Practice Address - Street 1:5120 E CENTRAL A
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-681-3840
Practice Address - Fax:316-684-5136
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7500074901Medicaid
KS7500074901Medicaid