Provider Demographics
NPI:1366714917
Name:PENNER, WILLIAM D (COTA/L)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:PENNER
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3734 PIEDRAS NEGRAS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7671
Mailing Address - Country:US
Mailing Address - Phone:575-642-0920
Mailing Address - Fax:
Practice Address - Street 1:3734 PIEDRAS NEGRAS DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7671
Practice Address - Country:US
Practice Address - Phone:575-642-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-29
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2505224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant