Provider Demographics
NPI:1396165833
Name:MOTLEY-PENN, WILDA (MA, LLPC)
Entity type:Individual
Prefix:
First Name:WILDA
Middle Name:
Last Name:MOTLEY-PENN
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24526 PINE GRV
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2309
Mailing Address - Country:US
Mailing Address - Phone:248-615-3492
Mailing Address - Fax:
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1024
Practice Address - Country:US
Practice Address - Phone:313-833-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health