Provider Demographics
NPI:1598255523
Name:PENNELL, ERICKA GISELLE (RBT 17-37783)
Entity Type:Individual
Prefix:MRS
First Name:ERICKA
Middle Name:GISELLE
Last Name:PENNELL
Suffix:
Gender:F
Credentials:RBT 17-37783
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 DARWIN DR
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-1473
Mailing Address - Country:US
Mailing Address - Phone:815-713-8520
Mailing Address - Fax:
Practice Address - Street 1:1065 DARWIN DR
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-1473
Practice Address - Country:US
Practice Address - Phone:815-713-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-37783106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician