Provider Demographics
NPI:1992022321
Name:PENNOYER, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PENNOYER
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 1:90 KETTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-2222
Mailing Address - Country:US
Mailing Address - Phone:203-341-0495
Mailing Address - Fax:203-226-7724
Practice Address - Street 1:8 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3511
Practice Address - Country:US
Practice Address - Phone:203-341-0495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-25
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical