Healthcare Provider Details

I. General information

NPI: 1952240830
Provider Name (Legal Business Name): CHRISTOPHER PENNYWELL SR. CTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47370 WARM SPRINGS BLVD
FREMONT CA
94539-7458
US

IV. Provider business mailing address

4476 N PHOENIX AVE
FRESNO CA
93723-9583
US

V. Phone/Fax

Practice location:
  • Phone: 559-681-3917
  • Fax:
Mailing address:
  • Phone: 559-681-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210146422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: