Provider Demographics
NPI:1699366765
Name:ASHFORD, PENELOPE DENISE (SAC-IT)
Entity Type:Individual
Prefix:MRS
First Name:PENELOPE
Middle Name:DENISE
Last Name:ASHFORD
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SENTINEL DR.
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189
Mailing Address - Country:US
Mailing Address - Phone:262-549-9449
Mailing Address - Fax:
Practice Address - Street 1:325 SENTINEL DR.
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189
Practice Address - Country:US
Practice Address - Phone:262-549-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19308-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)