Provider Demographics
NPI:1750633129
Name:PENNELLO, ROBERT S SR (LCMHCS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:S
Last Name:PENNELLO
Suffix:SR
Gender:M
Credentials:LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WAXHAW PKWY STE E110
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5029
Mailing Address - Country:US
Mailing Address - Phone:919-522-1559
Mailing Address - Fax:
Practice Address - Street 1:136 WAXHAW PKWY STE E110
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5029
Practice Address - Country:US
Practice Address - Phone:919-522-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS8956101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional