Provider Demographics
NPI:1629330477
Name:PENICK, YVETTE
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:PENICK
Suffix:
Gender:F
Credentials:
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 35192
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-0192
Mailing Address - Country:US
Mailing Address - Phone:310-770-6792
Mailing Address - Fax:
Practice Address - Street 1:5701 W SLAUSON AVE STE 140
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6503
Practice Address - Country:US
Practice Address - Phone:310-770-6792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70359106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist