Provider Demographics
NPI:1962277624
Name:RAYMOND, PENNIE
Entity type:Individual
Prefix:
First Name:PENNIE
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENNIE
Other - Middle Name:GEORGIA
Other - Last Name:RAYMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT-IT
Mailing Address - Street 1:PO BOX 1561
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-1561
Mailing Address - Country:US
Mailing Address - Phone:817-627-4879
Mailing Address - Fax:
Practice Address - Street 1:2211 OREGON ST STE N
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-7001
Practice Address - Country:US
Practice Address - Phone:817-627-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP2500X
WI1067-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional