MEDICARE: MS. HELENE PENZA MA CAGS ACS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MHC00012	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71372	OTHER	RI	BC
2	6254338	OTHER		UHC

General Provider Information

NPI Number	:	1164448205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HELENE PENZA MA CAGS ACS

Provider Business Mailing Address
First Line	:	150 HIGH SERVICE AVENUE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02911-3020
Country	:	US
Telephone Number	:	401-354-4318
Fax Number	:	401-354-0018

Provider Business Practice Location Address
First Line	:	150 HIGH SERVICE AVENUE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02911-3020
Country	:	US
Telephone Number	:	401-354-4318
Fax Number	:	401-354-0018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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