Provider Demographics
NPI:1770021685
Name:PENNYBROOK, KIMBERLY AVANNGELINE (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AVANNGELINE
Last Name:PENNYBROOK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:20283 1ST AVE NE
Mailing Address - Street 2:A-5
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9047
Mailing Address - Country:US
Mailing Address - Phone:253-372-2412
Mailing Address - Fax:
Practice Address - Street 1:18978 FRONT ST NE # B
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7353
Practice Address - Country:US
Practice Address - Phone:253-372-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW606828451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical