Provider Demographics
NPI:1851116081
Name:PENZO, DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PENZO
Suffix:
Gender:M
Credentials:LCSW
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 772
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-0772
Mailing Address - Country:US
Mailing Address - Phone:850-687-0569
Mailing Address - Fax:
Practice Address - Street 1:310 E BYRD AVE
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-3068
Practice Address - Country:US
Practice Address - Phone:850-547-5114
Practice Address - Fax:850-547-1709
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical