Provider Demographics
NPI:1902404478
Name:PENNINGTON, TRACY (CSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 MEADOWCREST DR
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-6484
Mailing Address - Country:US
Mailing Address - Phone:502-445-4074
Mailing Address - Fax:
Practice Address - Street 1:5722 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4156
Practice Address - Country:US
Practice Address - Phone:502-492-7455
Practice Address - Fax:502-921-0222
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY255159104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker