Provider Demographics
NPI:1881790624
Name:PENNER, LYNDAL (LCP, LCMFT)
Entity type:Individual
Prefix:
First Name:LYNDAL
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:LCP, LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 W 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-3513
Mailing Address - Country:US
Mailing Address - Phone:620-669-0736
Mailing Address - Fax:
Practice Address - Street 1:1715 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1105
Practice Address - Country:US
Practice Address - Phone:620-665-2240
Practice Address - Fax:620-665-2276
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS142103T00000X
KS046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098120AMedicaid