Provider Demographics
NPI:1760547723
Name:PENNINGTON, TINA BATES (LPC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:BATES
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:LPC
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 2356
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-2356
Mailing Address - Country:US
Mailing Address - Phone:417-848-7356
Mailing Address - Fax:417-725-7701
Practice Address - Street 1:308 N LAUREL LN
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-8582
Practice Address - Country:US
Practice Address - Phone:417-848-7356
Practice Address - Fax:417-725-7701
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000153606101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11564203OtherCACQ PROVIDER ID
MO2000153606OtherL.P.C. LICENSE NUMBER
MO494644305Medicaid