Healthcare Provider Details

I. General information

NPI: 1073749982
Provider Name (Legal Business Name): RAYMOND PENNER LSCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E 30TH AVE
HUTCHINSON KS
67502
US

IV. Provider business mailing address

2700 E 30TH AVE
HUTCHINSON KS
67502
US

V. Phone/Fax

Practice location:
  • Phone: 620-663-8484
  • Fax:
Mailing address:
  • Phone: 620-663-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7410
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05301
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: