Provider Demographics
NPI:1013760701
Name:PENNYWELL, LAVE WILSON
Entity Type:Individual
Prefix:
First Name:LAVE
Middle Name:WILSON
Last Name:PENNYWELL
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 1:45 SANIBEL ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-6944
Mailing Address - Country:US
Mailing Address - Phone:919-410-5287
Mailing Address - Fax:
Practice Address - Street 1:45 SANIBEL ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-6944
Practice Address - Country:US
Practice Address - Phone:919-410-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0184871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical