Provider Demographics
NPI:1780759712
Name:PENN, ROBERTA RAE (MA)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:RAE
Last Name:PENN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049
Mailing Address - Country:US
Mailing Address - Phone:610-965-6418
Mailing Address - Fax:
Practice Address - Street 1:555 HARRISON ST
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049
Practice Address - Country:US
Practice Address - Phone:610-965-6418
Practice Address - Fax:610-965-6382
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006824L103T00000X
PAPC000394101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor