Provider Demographics
NPI:1417385337
Name:PRATT, PENELOPE KATHLEEN
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:KATHLEEN
Last Name:PRATT
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 1:3501 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5153
Mailing Address - Country:US
Mailing Address - Phone:506-258-4457
Mailing Address - Fax:413-445-6242
Practice Address - Street 1:3501 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5153
Practice Address - Country:US
Practice Address - Phone:505-258-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2023-08841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2023-0884OtherNM SW LICENSE
MA126548OtherMA SW LICENSE
15987084OtherCAQH