Provider Demographics
NPI:1922267079
Name:PENNIMAN, KYLE JAMISON (MSW, LISAC, CADAC)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JAMISON
Last Name:PENNIMAN
Suffix:
Gender:M
Credentials:MSW, LISAC, CADAC
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:PENNIMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LISAC, CADAC
Mailing Address - Street 1:4020 N 20TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-6032
Mailing Address - Country:US
Mailing Address - Phone:602-535-6468
Mailing Address - Fax:
Practice Address - Street 1:4020 N 20TH ST STE 302
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6032
Practice Address - Country:US
Practice Address - Phone:602-535-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)