Provider Demographics
NPI:1780176479
Name:PENNY LANE THERAPY LLC
Entity type:Organization
Organization Name:PENNY LANE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-0WNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:CHASTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:405-919-7009
Mailing Address - Street 1:4416 N WESTERN AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5256
Mailing Address - Country:US
Mailing Address - Phone:405-919-7009
Mailing Address - Fax:
Practice Address - Street 1:4416 N WESTERN AVE STE 207
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5256
Practice Address - Country:US
Practice Address - Phone:405-919-7009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6368261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)