Provider Demographics
NPI:1649403114
Name:PARKS, PENNY LASALLE (MS)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LASALLE
Last Name:PARKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1851
Mailing Address - Country:US
Mailing Address - Phone:414-258-6000
Mailing Address - Fax:414-258-3700
Practice Address - Street 1:7251 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1851
Practice Address - Country:US
Practice Address - Phone:414-258-6000
Practice Address - Fax:414-258-3700
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI653-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional