Provider Demographics
NPI:1679750186
Name:PENNA, KAREN GAYLE (ED S)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:GAYLE
Last Name:PENNA
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-9688
Mailing Address - Country:US
Mailing Address - Phone:407-971-5968
Mailing Address - Fax:321-248-0141
Practice Address - Street 1:416A N FERNCREEK AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5432
Practice Address - Country:US
Practice Address - Phone:407-898-7798
Practice Address - Fax:407-894-6010
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS880103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool