Provider Demographics
NPI:1912474578
Name:PENEZIC, JOHN EDWARD (PSYD, LPA)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:PENEZIC
Suffix:
Gender:M
Credentials:PSYD, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-8176
Mailing Address - Country:US
Mailing Address - Phone:502-536-8149
Mailing Address - Fax:
Practice Address - Street 1:3001 W HIGHWAY 146
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9123
Practice Address - Country:US
Practice Address - Phone:502-536-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245147103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist