Provider Demographics
NPI:1942610084
Name:PENWELL-WAINES, LAUREN MARIE
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:MARIE
Last Name:PENWELL-WAINES
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-5170
Mailing Address - Fax:704-316-5172
Practice Address - Street 1:19485 OLD JETTON RD STE 100
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6583
Practice Address - Country:US
Practice Address - Phone:704-316-5170
Practice Address - Fax:704-316-5172
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003720103TC0700X
NC5166103T00000X
VA0810005005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical