Provider Demographics
NPI:1740413962
Name:PENNER, MATTHEW (LSCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67504-0772
Mailing Address - Country:US
Mailing Address - Phone:620-200-4800
Mailing Address - Fax:
Practice Address - Street 1:101 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-7147
Practice Address - Country:US
Practice Address - Phone:620-200-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS42271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1000981201Medicaid