Provider Demographics
NPI:1659805604
Name:PENNER, TRENTON (LPC, MCP)
Entity type:Individual
Prefix:
First Name:TRENTON
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:LPC, MCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DACOMA
Mailing Address - State:OK
Mailing Address - Zip Code:73731-9529
Mailing Address - Country:US
Mailing Address - Phone:580-748-0946
Mailing Address - Fax:
Practice Address - Street 1:1052 11TH ST
Practice Address - Street 2:
Practice Address - City:DACOMA
Practice Address - State:OK
Practice Address - Zip Code:73731-9529
Practice Address - Country:US
Practice Address - Phone:580-748-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101YM0800X
OK11970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker