Provider Demographics
NPI:1689362659
Name:PENNELLE, LAURA (LCSW, JD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PENNELLE
Suffix:
Gender:F
Credentials:LCSW, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5075 NARRAGANSETT AVE UNIT 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3001
Mailing Address - Country:US
Mailing Address - Phone:619-550-8875
Mailing Address - Fax:
Practice Address - Street 1:5075 NARRAGANSETT AVE UNIT 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3001
Practice Address - Country:US
Practice Address - Phone:619-550-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1055341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical