Provider Demographics
NPI:1235667601
Name:DR GERALD W PENNIE
Entity type:Organization
Organization Name:DR GERALD W PENNIE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LEAD COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, NCC
Authorized Official - Phone:713-417-6057
Mailing Address - Street 1:2735 GENOA AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-7848
Mailing Address - Country:US
Mailing Address - Phone:713-417-6057
Mailing Address - Fax:
Practice Address - Street 1:3805 22ND ST STE 1C
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1142
Practice Address - Country:US
Practice Address - Phone:713-417-6057
Practice Address - Fax:713-417-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72286261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health