Provider Demographics
NPI:1568694966
Name:PENNER, KELLI (MS, LMFT 79102)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PENNER
Suffix:
Gender:F
Credentials:MS, LMFT 79102
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 91081
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-1081
Mailing Address - Country:US
Mailing Address - Phone:323-485-0189
Mailing Address - Fax:
Practice Address - Street 1:5314 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4004
Practice Address - Country:US
Practice Address - Phone:626-765-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 65537106H00000X
CALMFT 79102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist