Healthcare Provider Details

I. General information

NPI: 1548700891
Provider Name (Legal Business Name): KENDRA PENSKI LICENSED CLINICAL SOCIAL WORKER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2254 SAN DIEGO AVE
SAN DIEGO CA
92110-2944
US

IV. Provider business mailing address

PO BOX 371446
SAN DIEGO CA
92137-1446
US

V. Phone/Fax

Practice location:
  • Phone: 619-363-1920
  • Fax: 619-363-4623
Mailing address:
  • Phone: 619-363-1920
  • Fax: 619-363-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KENDRA PENSKI
Title or Position: OWNER
Credential:
Phone: 619-363-1920