MEDICARE: MS. CAROL L PENICK 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	LPC #3028	NC

General Provider Information

NPI Number	:	1679659981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL L PENICK LPC

Provider Business Mailing Address
First Line	:	PO BOX 5763
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27113-5763
Country	:	US
Telephone Number	:	336-310-3348
Fax Number	:

Provider Business Practice Location Address
First Line	:	942 W 4TH ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-2582
Country	:	US
Telephone Number	:	336-607-7555
Fax Number	:	336-607-7555

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

Provider Enumeration Date	:	10/29/2006
Last Update Date	:	07/08/2007

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