Provider Demographics
NPI:1689211674
Name:PENN, RAINA (TLLP)
Entity Type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:PENN
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22162 MALDEN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTN HLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3858
Mailing Address - Country:US
Mailing Address - Phone:313-377-2570
Mailing Address - Fax:
Practice Address - Street 1:6425 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1974
Practice Address - Country:US
Practice Address - Phone:313-846-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018212103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist