Provider Demographics
NPI:1356876692
Name:SULLENGER, PENNY ROSE (LMFT)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:ROSE
Last Name:SULLENGER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24595 TARAZONA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2350
Mailing Address - Country:US
Mailing Address - Phone:949-830-4787
Mailing Address - Fax:
Practice Address - Street 1:30131 TOWN CENTER DR STE 280
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2086
Practice Address - Country:US
Practice Address - Phone:714-334-0148
Practice Address - Fax:949-855-0384
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC45009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist