Provider Demographics
NPI:1336351162
Name:PENNER, ERIC REGAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:REGAN
Last Name:PENNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 N SHADOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-6929
Mailing Address - Country:US
Mailing Address - Phone:520-544-2848
Mailing Address - Fax:
Practice Address - Street 1:6600 N ORACLE RD STE 110
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5676
Practice Address - Country:US
Practice Address - Phone:520-275-4526
Practice Address - Fax:520-296-7410
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2011103TC0700X
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool