Provider Demographics
NPI:1679649206
Name:PENN, KENIQUE D (LPC)
Entity Type:Individual
Prefix:MISS
First Name:KENIQUE
Middle Name:D
Last Name:PENN
Suffix:
Gender:F
Credentials:LPC
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 250
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-0250
Mailing Address - Country:US
Mailing Address - Phone:770-316-5435
Mailing Address - Fax:770-667-3879
Practice Address - Street 1:5755 N POINT PKWY
Practice Address - Street 2:SUITE 256
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:770-667-3877
Practice Address - Fax:770-667-3879
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA673603439AMedicaid