Provider Demographics
NPI:1942617519
Name:KLEIN, PENNY JEAN (LISAC)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JEAN
Last Name:KLEIN
Suffix:
Gender:F
Credentials:LISAC
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 2779
Mailing Address - Street 2:
Mailing Address - City:ARIZONA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85123-1040
Mailing Address - Country:US
Mailing Address - Phone:520-466-8850
Mailing Address - Fax:520-466-8851
Practice Address - Street 1:4055 NORTH CAMERON DRIVE
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-1040
Practice Address - Country:US
Practice Address - Phone:520-466-8850
Practice Address - Fax:520-466-8851
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10645101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor