Provider Demographics
NPI:1669802575
Name:LENTZ, PENELOPE BACK (LPAT)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:BACK
Last Name:LENTZ
Suffix:
Gender:F
Credentials:LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2402
Mailing Address - Country:US
Mailing Address - Phone:502-468-5429
Mailing Address - Fax:
Practice Address - Street 1:128 N CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2402
Practice Address - Country:US
Practice Address - Phone:502-468-5429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health