Healthcare Provider Details

I. General information

NPI: 1962177881
Provider Name (Legal Business Name): PHILLIP PENN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 HUGHES WAY POD B 2ND FLOOR
LONG BEACH CA
90810-1864
US

IV. Provider business mailing address

1500 HUGHES WAY POD B 2ND FLOOR
LONG BEACH CA
90810-1864
US

V. Phone/Fax

Practice location:
  • Phone: 213-954-0007
  • Fax:
Mailing address:
  • Phone: 213-954-0007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: