Provider Demographics
NPI:1962664656
Name:PENRICE, LA VERNE
Entity Type:Individual
Prefix:
First Name:LA VERNE
Middle Name:
Last Name:PENRICE
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 1:820 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0002
Mailing Address - Country:US
Mailing Address - Phone:909-387-7200
Mailing Address - Fax:909-386-8520
Practice Address - Street 1:820 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0002
Practice Address - Country:US
Practice Address - Phone:909-387-7200
Practice Address - Fax:909-386-8520
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50433106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist