MEDICARE: REGINA PENN MS, LPC

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	101YP2500X	Professional Counselor	11436-125	WI

General Provider Information

NPI Number	:	1326711607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA PENN MS, LPC

Provider Business Mailing Address
First Line	:	6650 W STATE ST STE D-188
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-2827
Country	:	US
Telephone Number	:	414-667-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	6650 W STATE ST STE D-188
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-2827
Country	:	US
Telephone Number	:	414-667-7575
Fax Number	:

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

Provider Enumeration Date	:	07/31/2021
Last Update Date	:	11/26/2024

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