Healthcare Provider Details

I. General information

NPI: 1164314803
Provider Name (Legal Business Name): MOLLIBETH PENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N EAGLESON AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

2003 W ROSS LN
BLOOMINGTON IN
47403-2041
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-5711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005525A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: