Provider Demographics
NPI:1609034479
Name:ERIC R PENNER PHD
Entity Type:Organization
Organization Name:ERIC R PENNER PHD
Other - Org Name:ERIC R. PENNER PHD, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-275-4526
Mailing Address - Street 1:6737 N SHADOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6929
Mailing Address - Country:US
Mailing Address - Phone:520-275-4526
Mailing Address - Fax:520-296-7410
Practice Address - Street 1:6600 N ORACLE RD STE 110
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5676
Practice Address - Country:US
Practice Address - Phone:520-275-4526
Practice Address - Fax:520-296-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2011103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty