Provider Demographics
NPI:1063874022
Name:PENZAK, HAILEY (MS, TLLP)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:PENZAK
Suffix:
Gender:F
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:
Other - Last Name:PARIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, TLLP
Mailing Address - Street 1:43511 LANCELOT DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-4803
Mailing Address - Country:US
Mailing Address - Phone:313-550-0586
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-397-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016362103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical