Provider Demographics
NPI:1891419701
Name:PENAR, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PENAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3056 SEEKONK AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8937
Mailing Address - Country:US
Mailing Address - Phone:847-323-4239
Mailing Address - Fax:
Practice Address - Street 1:1121 E MAIN ST STE 310
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2276
Practice Address - Country:US
Practice Address - Phone:630-277-9731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.008307104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker