Provider Demographics
NPI:1689320244
Name:BURT, PENNY DARNELL
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:DARNELL
Last Name:BURT
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 1:10531 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2604
Mailing Address - Country:US
Mailing Address - Phone:317-683-8114
Mailing Address - Fax:
Practice Address - Street 1:10531 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2604
Practice Address - Country:US
Practice Address - Phone:317-282-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99120795A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health