Provider Demographics
NPI:1790835619
Name:FIFE, PENNY JEAN (MS, MFT, LADC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JEAN
Last Name:FIFE
Suffix:
Gender:F
Credentials:MS, MFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9402 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-8312
Mailing Address - Country:US
Mailing Address - Phone:702-228-3306
Mailing Address - Fax:
Practice Address - Street 1:9402 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-8312
Practice Address - Country:US
Practice Address - Phone:702-228-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0708106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist