Provider Demographics
NPI:1952761629
Name:PENFOUND, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:PENFOUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4897 KARL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-5147
Mailing Address - Country:US
Mailing Address - Phone:614-846-2588
Mailing Address - Fax:
Practice Address - Street 1:4488 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-5610
Practice Address - Country:US
Practice Address - Phone:614-639-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
E.2102524-SUPV101YM0800X
OHOH30537221041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool