Healthcare Provider Details

I. General information

NPI: 1497666515
Provider Name (Legal Business Name): EMILY PENWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W MAIN ST STE 1
LEESBURG FL
34748-2842
US

IV. Provider business mailing address

1650 W MAIN ST STE 1
LEESBURG FL
34748-2842
US

V. Phone/Fax

Practice location:
  • Phone: 352-314-3760
  • Fax: 352-314-2909
Mailing address:
  • Phone: 352-314-3760
  • Fax: 352-314-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2842170
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: