Provider Demographics
NPI:1336390525
Name:OBERHARDT, PENELOPE MEG (LCSW)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:MEG
Last Name:OBERHARDT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 FOOTHILL BLVD # 414
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3511
Mailing Address - Country:US
Mailing Address - Phone:818-839-0875
Mailing Address - Fax:
Practice Address - Street 1:2846 MARY ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3418
Practice Address - Country:US
Practice Address - Phone:310-562-5819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALSW290801041C0700X
CAASW23946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker