Provider Demographics
NPI:1720463086
Name:PENNEKAMP, CECILIA FASANELLA (OT)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:FASANELLA
Last Name:PENNEKAMP
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CECILIA
Other - Middle Name:GRACE
Other - Last Name:FASANELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:10839 QUARRY PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4681
Mailing Address - Country:US
Mailing Address - Phone:210-257-6260
Mailing Address - Fax:210-451-8058
Practice Address - Street 1:10839 QUARRY PARK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-4681
Practice Address - Country:US
Practice Address - Phone:102-576-2602
Practice Address - Fax:210-451-8058
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1470225X00000X
TX116910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist