Provider Demographics
NPI:1578586152
Name:PENICK, MARY E (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:PENICK
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 OLD SOLOMONS ISLAND RD STE U7
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3848
Mailing Address - Country:US
Mailing Address - Phone:410-266-8345
Mailing Address - Fax:410-266-6278
Practice Address - Street 1:108 OLD SOLOMONS ISLAND RD STE U7
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3848
Practice Address - Country:US
Practice Address - Phone:410-266-8345
Practice Address - Fax:410-266-6278
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD160121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD033890700Medicaid
191912ZA4BMedicare PIN