Provider Demographics
NPI:1649282500
Name:PENBERTHY-MACKI, MARY (LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PENBERTHY-MACKI
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1597 AVENUE D
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-3010
Mailing Address - Country:US
Mailing Address - Phone:406-238-9890
Mailing Address - Fax:406-294-0967
Practice Address - Street 1:1597 AVENUE D
Practice Address - Street 2:SUITE 1
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-3010
Practice Address - Country:US
Practice Address - Phone:406-238-9890
Practice Address - Fax:406-294-0967
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT701LCPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000075016OtherBCBS
MT0255119Medicaid