Healthcare Provider Details

I. General information

NPI: 1083055909
Provider Name (Legal Business Name): THOMAS PENNINGTON MBA, LCAC, CADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E MAIN ST STE 200
RICHMOND IN
47374-4358
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-935-5390
  • Fax:
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-741-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000619A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: