Provider Demographics
NPI:1821142217
Name:PANNELL, KENNY ZACK (MED, LCPC)
Entity Type:Individual
Prefix:MR
First Name:KENNY
Middle Name:ZACK
Last Name:PANNELL
Suffix:
Gender:M
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 TRAILS END RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-9332
Mailing Address - Country:US
Mailing Address - Phone:406-889-5577
Mailing Address - Fax:406-889-5576
Practice Address - Street 1:57 TRAILS END RD
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9332
Practice Address - Country:US
Practice Address - Phone:406-889-5577
Practice Address - Fax:406-889-5576
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT533101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional