Provider Demographics
NPI:1487147450
Name:PENNY, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:PENNY
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 1:5925 CLEVELAND AVE., SUITE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231
Mailing Address - Country:US
Mailing Address - Phone:614-776-4646
Mailing Address - Fax:
Practice Address - Street 1:5925 CLEVELAND AVE., SUITE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231
Practice Address - Country:US
Practice Address - Phone:614-776-4646
Practice Address - Fax:740-345-7454
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)