Healthcare Provider Details

I. General information

NPI: 1942672126
Provider Name (Legal Business Name): GRETCHEN PENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 OLD TOWN AVE STE 209A
SAN DIEGO CA
92110-2967
US

IV. Provider business mailing address

2121 5TH AVE STE 214
SAN DIEGO CA
92101-2139
US

V. Phone/Fax

Practice location:
  • Phone: 619-202-5258
  • Fax:
Mailing address:
  • Phone: 619-272-6858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW 67771
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: