Provider Demographics
NPI:1720143381
Name:PENZA, FREDERICK W (EDD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:W
Last Name:PENZA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-6021
Mailing Address - Country:US
Mailing Address - Phone:978-475-6169
Mailing Address - Fax:
Practice Address - Street 1:6 ENFIELD DR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-6021
Practice Address - Country:US
Practice Address - Phone:978-475-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA871103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0505366Medicaid
MAWO1265OtherBCBS PROVIDER NUMBER
MAWO1265Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER