Provider Demographics
NPI:1215008842
Name:PENN, NICOLA MARIE (LPC, LMFT)
Entity type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:MARIE
Last Name:PENN
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2112
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-2112
Mailing Address - Country:US
Mailing Address - Phone:870-793-7162
Mailing Address - Fax:870-612-5173
Practice Address - Street 1:548 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-5405
Practice Address - Country:US
Practice Address - Phone:870-793-7162
Practice Address - Fax:870-612-5173
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0405022101YM0800X
ARM0405001106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X867OtherAR BLUE CROSS BLUE SHIEL