Provider Demographics
NPI:1609957505
Name:PENNEBAKER, ROBERT (PMHNP-BC, LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PENNEBAKER
Suffix:
Gender:M
Credentials:PMHNP-BC, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 BREEZEWOOD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5281
Mailing Address - Country:US
Mailing Address - Phone:910-491-1134
Mailing Address - Fax:910-491-9781
Practice Address - Street 1:2931 BREEZEWOOD AVE STE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5281
Practice Address - Country:US
Practice Address - Phone:910-491-1134
Practice Address - Fax:910-491-9781
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0020321041C0700X
NC5005524363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2866132AMedicare UPIN