Provider Demographics
NPI:1952749574
Name:PENZA, CHRISTINA M
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:PENZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:M
Other - Last Name:MATSKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 78000
Mailing Address - Street 2:DEPT. 781625
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:500 E MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5369
Practice Address - Country:US
Practice Address - Phone:614-355-6300
Practice Address - Fax:614-355-6310
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800532101YM0800X
OHC.1300026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid