Healthcare Provider Details

I. General information

NPI: 1215008842
Provider Name (Legal Business Name): NICOLA MARIE PENN LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 N CENTRAL AVE
BATESVILLE AR
72501-5405
US

IV. Provider business mailing address

PO BOX 2112
BATESVILLE AR
72503-2112
US

V. Phone/Fax

Practice location:
  • Phone: 870-793-7162
  • Fax: 870-612-5173
Mailing address:
  • Phone: 870-793-7162
  • Fax: 870-612-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP0405022
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM0405001
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: